Mountain State Medical Policy Bulletin
Section: Durable Medical Equipment
Number: E-43
Topic: Infrared Heating Pad Systems
Effective Date: May 21, 2007
Issued Date: May 21, 2007
Date Last Reviewed: 04/2007

General Policy Guidelines

Indications and Limitations of Coverage

The infrared heating pad system (E0221) (e.g., Anodyne Therapy System) and any related accessories [e.g., replacement pad (A4639)] are considered experimental/investigational, and not eligible for reimbursement. Despite the fact that this system has received FDA approval, there is a lack of long-term studies demonstrating the efficacy of this device. A participating, preferred, or network provider can bill the member for the denied service.

Description

An infrared heating pad system, also known as a monochromatic infrared energy (MIRE) device, consists of a power source and a pad or pads containing mechanisms (e.g., luminous gallium aluminum arsinide diodes) that generate infrared or near infrared light. The labeled indication is for “increasing circulation and decreasing pain.” MIRE devices have been investigated as a treatment of multiple conditions including cutaneous ulcers, diabetic neuropathy, musculoskeletal and soft tissue injuries, including temporomandibular disorders, tendonitis, capsulitis, and myofascial pain.


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

A4639E0221    

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

MPRM 1.01.22

Augmentation of Wound Healing Using Monochromatic Infrared Energy, Advances in Wound Care, January/February 1999; 12(1):35-40

Symptomatic Reversal of Peripheral Neuropathy in Patients with Diabetes, Journal of the American Podiatric Medical Association, Vol. 92, No. 3, March 2002

Neurogenic positional pedal neuritis, Common pedal manifestations of spinal stenosis,  J Am Podiatr Med Assoc, May 1, 2003; 93(3): 174-84

Improvement of sensory impairment in patients with peripheral neuropathy, Endocr Pract, January 1, 2004; 10(1): 24-30

Restoration of sensation, reduced pain, and improved balance in subjects with diabetic peripheral neuropathy: a double-blind, randomized, placebo-controlled study with monochromatic near-infrared treatment, Diabetes Care, January 1, 2004; 27(1): 168-72

Monochromatic infrared energy,  New hope for painful, numb feet?, Diabetes Self Manag, March 1, 2004; 21(2): 52, 54-6

Reversal of Diabetic Peripheral Neuropathy and New Wound Incidence: The Role of MIRE, Adv Skin Wound Care, July 1, 2004; 17(6): 295-300

CMS NCD for Infrared Therapy Devices (270.6)

TriCenturion LCD for Infrared Heating Pad Systems (L12873)

Improved Sensitivity in Patients with Peripheral Neuropathy: Effects of Monochromatic Infrared Photo Energy. The Journal of the American Podiatric Medical Association, March-April 2005; 95(2):143-7

Management of Diabetic Peripheral Neuropathy, Clinical Diabetes, 2005, Vol. 23

The Effect of Monochromatic Infrared Energy on Sensation in Patients With Diabetic Peripheral Neuropathy: A double-blind, placebo-controlled study. Diabetes Care, Dec 2005; 28(12):2896-900
 
Improved Foot Sensitivity and Pain Reduction in Patients with Peripheral Neuropathy After Treatment with Monochromatic Infrared Photo Energy – MIRE, Journal of Diabetes and Its Complications, Mar-Apr 2006; 20(2):81-7

View Previous Versions

[Version 001 of E-43]

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.