E0769, Electrical stimulation or electromagnetic wound treatment device, not otherwise
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Documentation to support the covered ICD-10 diagnosis (examples listed in policy: M72.2; M77.30 - M77.32).
- For combined steroid/anesthetic injection: documentation that conservative treatments have failed — e.g., attempted stretching exercises, over-the-counter silicone heel shoe inserts, and 2 to 3 weeks of non-steroidal anti-inflammatory drugs (per the policy text: "when conservative treatments (e.g., stretching exercises, over-the-counter silicone heel shoe inserts, and 2 to 3 weeks of non-steroidal anti-inflammatory drugs) have failed").
- For endoscopic plantar fasciotomy: documentation of intractable plantar fasciitis or heel spur syndrome and failure of a 6-month trial of conservative therapy (per the policy text: "who have failed a 6-month trial of conservative therapy").
Key Coverage Criteria
- Indication: Electromagnetic therapy for wounds/ulcers is not medically necessary due to insufficient evidence of efficacy across wound types (arterial ulcers, chronic pressure ulcers, diabetic foot ulcers, soft tissue injuries, venous stasis ulcers).
- Plantar fasciitis (including chronic/recalcitrant plantar fasciitis)
- Painful calcaneal spur and plantar heel pain (conditions being evaluated for the listed treatments)
- Combined steroid/anesthetic injection medically necessary for the treatment of plantar fascia when conservative treatments (e.g., stretching exercises, over-the-counter silicone heel shoe inserts, and 2 to 3 weeks of non-steroidal anti-inflammatory drugs) have failed.
- Endoscopic plantar fasciotomy medically necessary as an alternative to conventional open plantar fasciotomy for members with intractable plantar fasciitis or heel spur syndrome who have failed a 6-month trial of conservative therapy.
- CPT codes covered if selection criteria are met: 20550 (Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")) and 29893 (Endoscopic plantar fasciotomy).
11 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-electromagnetic-therapy-wounds, Electromagnetic Therapy for Wounds
AETNA-CPB-0235, Plantar Fasciitis Treatments
MED201.027, Electrostimulation and Electromagnetic Therapy for Treating Wounds
BCBSIL-MED201.027
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