Mountain State Medical Policy Bulletin
Section: Durable Medical Equipment
Number: E-33
Topic: H-wave Electrical Stimulation
Effective Date: August 1, 2005
Issued Date: May 29, 2006
Date Last Reviewed: 05/2006

General Policy Guidelines

Indications and Limitations of Coverage

H-wave stimulation is experimental/investigational. Review of available literature reveals a lack of controlled clinical trials that prove the effectiveness of the procedure. As such, the H-wave device used in the home and H-wave stimulation performed in the provider's office are not covered. A participating, preferred, or network provider can bill the member for the denied service.

NOTE:
H-wave electrical stimulation must be distinguished from the H-waves that are a component of electromyography. For guidelines on electromyography, see Medical Policy Bulletin M-28, Electromyography (EMG).

Description

H-wave stimulation is a form of electrical stimulation that differs from other forms of electrical stimulation, such as transcutaneous electrical nerve stimulation (TENS), in terms of its wave form. H-wave stimulation has been used for the treatment of pain related to a variety of etiologies, such as diabetic neuropathy, muscle sprains, temporomandibular joint dysfunctions or reflex sympathetic dystrophy. H-wave stimulation has also been used to accelerate healing of wounds, such as diabetic ulcers. While H-wave stimulation may be performed in the physician's office, devices for H-wave stimulation in the home are also available.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes


Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

H-wave Electrical Stimulation, Medical Policy Reference Manual, Policy 1.01.13, 03/2005

H-wave Electrical Stimulation, Consortium Health Plans, Inc., Policy 1.01.13, 01/1998

Diabetic peripheral neuropathy: amelioration of pain with transcutaneous electrostimulation, Diabetes Care, 1997;20(11):1702-5

Diabetic peripheral neuropathy: Effectiveness of electrotherapy and amitriptyline for symptomatic relief, Diabetes Care, 1998;21(8):1322-5

Beneficial effects of electrical stimulation on neuropathic symptoms in diabetes patients, J Foot Ankle Surg, 1998;37(3):191-4

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[Version 001 of E-33]

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.