E0721, Transcutaneous electrical nerve stimulator for nerves in the auricular region
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Documentation Required
- Claims may require medical records documentation to assess whether the member meets the clinical criteria for coverage; however, documentation does not guarantee coverage.
- Evidence of a 30-day trial of conventional wound management with failure to demonstrate measurable signs of improved healing (e.g., signs of epithelialization and reduction in ulcer size) including documentation of optimization of nutritional status, use of moist dressings, and debridement.
- Documentation that electrical stimulation therapy for wound healing will be and is performed under the direct supervision of a medical professional with expertise in wound evaluation and management (policy statement: 'Electrical stimulation therapy is performed under the direct supervision of a medical professional with expertise in wound evaluation and management').
Key Coverage Criteria
- Electrical stimulation (HCPCS Code G0281) is considered medically necessary for the treatment of a chronic wound when ALL of the following criteria are met: Presence of ANY of the following chronic wound types: Stage 3 or stage 4 pressure injury; arterial ulcer; neuropathic (diabetic) ulcer; venous stasis ulcer.
- Electrical stimulation (HCPCS Code G0281) is considered medically necessary for the treatment of a chronic wound when ALL of the following criteria are met: Failure to demonstrate measurable signs of improved healing (e.g., signs of epithelialization and reduction in ulcer size) with a 30-day trial of conventional wound management, including optimization of nutritional status, moist dressings and debridement.
- Electrical stimulation (HCPCS Code G0281) is considered medically necessary for the treatment of a chronic wound when ALL of the following criteria are met: Electrical stimulation therapy is performed under the direct supervision of a medical professional with expertise in wound evaluation and management.
- Neuromuscular electrical stimulation (NMES) (HCPCS Code E0745) and related supplies (HCPCS Code A4595) are considered medically necessary when used as one component of a comprehensive rehabilitation program for the treatment of disuse atrophy when the nerve supply to the atrophied muscle is intact.
- Transcutaneous electrical nerve stimulator (TENS) (HCPCS Codes E0720, E0730) and related supplies (HCPCS Code A4595) are considered medically necessary for in-home use as an adjunct to conventional post-operative pain management within 30 days of surgery.
- Conductive garment (HCPCS Code E0731) is considered medically necessary when used in conjunction with a medically necessary in-home NMES or TENS device for ANY of the following clinical situations: The use of conventional electrodes, tapes or lead wires is not feasible either because the individual has a large area requiring treatment or a large number of sites requiring stimulation; The site(s) requiring stimulation (i.e., back) is/are difficult to reach with conventional electrodes, tapes or l [...]
12 Active Policies
ANTHEM-DME.00011, DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
UHC-POL-electrical-stimulation-treatment-pain-muscle-rehabilitation, Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
BCBSIL-SUR702.019, Cranial Electrotherapy Stimulation and Auricular Electrostimulation
BCBSMT-SUR702.019, Cranial Electrotherapy Stimulation and Auricular Electrostimulation
Related Codes
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