Mountain State Medical Policy Bulletin
Section: Durable Medical Equipment
Number: E-45
Topic: Interferential Stimulator
Effective Date: August 1, 2005
Issued Date: September 10, 2007
Date Last Reviewed: 07/2005

General Policy Guidelines

Indications and Limitations of Coverage

Payment may be made for an interferential stimulator (e.g., RS-4i, RS-4M, IF-II, INF Plus, Alpha Stim, Medstar 100)(E1399) when prescribed by a physician for use in the home for the following:

  • symptomatic relief and management of chronic pain ; or
  • reduction of edema; or
  • improvement in range of motion. 

Conditions other than those listed above will be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

Use code E1399 to report an interferential stimulator for home use. When you report code E1399, please include the term "interferential stimulator" in the narrative section of the electronic or paper claim.

NOTE:
When performed in a clinical setting, interferential therapy (IFT) is eligible for reimbursement under code 97014.

Coverage is subject to any applicable physical medicine and/or durable medical equipment (DME) limitation in the member's benefit contract.

Refer to Medical Policy Bulletin Z-7 for additional information on electrical nerve stimulation.

Description

Interferential stimulation is a type of electrical nerve stimulation that uses paired electrodes of two independent circuits carrying medium-frequency alternating currents. The electrodes are aligned on the skin so that the current flowing between each pair intersects at the underlying target. This maximizes the current permeating the tissues while minimizing unwanted stimulation of cutaneous nerves. Interferential stimulation has been established as a technique to reduce pain, improve range of motion, or promote local healing following various tissue injuries.


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

97014E1399    

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

The effects of home interferential therapy on post-operative pain, edema, and range of motion of the knee, Jarit GJ, Clin J Sport Med, 01-JAN-2003; 13(1): 16-20

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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.