DESCRIPTION
High-frequency electrical stimulation pulses with or without a low dose local anesthetic are proposed as a treatment for pain (e.g., neuropathy and chronic nerve conditions). This treatment is usually delivered in an office setting and performed by a licensed and certified clinician (e.g., physician, nurse practitioner, or another medical professional). The electrical stimulation frequency is delivered at a much higher range (e.g., up to 40,000 Hz) than with other forms of electrical stimulation such as TENS or interferential nerve stimulation (e.g., up to 4,400 Hz). An example of a high frequency electrical stimulation device is the Neurogenx NervePro, also known as the Neurogenx 4000Pro.
The treatments are usually delivered in two 20-minute sessions, one right after the other. The initial 20-minute session is performed at one frequency level with administration of a nerve block if needed. This combined approach is often called an integrated nerve block. Then the provider will deliver the second 20-minute session at the next higher frequency level. Nerve blocks are usually only performed during the first six treatment sessions.
POLICY
High frequency electrical stimulation pulses with or without a low dose local anesthetic for the treatment of pain is considered investigational.
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g., statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
ADDITIONAL INFORMATION
No randomized controlled studies were found in the published literature that would validate the efficacy of using high frequency electrical stimulation with or without a low dose anesthetic for the treatment of pain.
SOURCES
CMS.gov: Centers for Medicare & Medicaid Services. Palmetto GBA. (2021, July). Nerve blocks and electrostimulation for peripheral neuropathy. (LCD ID L37642). Retrieved June 30, 2023 from https://www.cms.gov.
Emanual, N., Broeke, V., Urdi, M., Mouraux, A., Manresa, J A B., & Torta, D.M.E. (2021). High-frequency electrical stimulation of cutaneous nociceptors differentially affects pain perception elicited by homotopic and heterotopic electrical stimuli. Journal of Neurophysiology, 126 (4), 1038-1044. (Level 5 evidence)
U. S. Food and Drug Administration. (1997, June). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K940954 (Synaptic 3000). Retrieved June 1, 2022 from http://www.accessdata.fda.gov.
Yang, H., Datta-Chaudjuri, T., George, S.J., Haider,, B., Wong, J., Helpler, T.D., Andersson, U. (2022). High-frequency electrical stimulation attenuates neuronal release of inflammatory mediators and ameliorates neuropathic pain. Bioelectronic Medicine, 8 (1), 16. doi: 10.1186/s42234-022-00098-8. (Level 5 evidence)
ORIGINAL EFFECTIVE DATE: 11/1/2022
MOST RECENT REVIEW DATE: 8/10/2023
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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