E0769 — Electrical stimulation or electromagnetic wound treatment device, not otherwise classified
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- None specified in this Medical Policy.
- Policy instructs to check the member specific benefit plan document and any applicable federal or state mandates when deciding coverage.
- 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").
Key Coverage Criteria
- None — Electromagnetic therapy is considered unproven and not medically necessary for treating wounds or ulcers.
- Conditions explicitly called out as examples where EMT is considered unproven/not medically necessary: arterial ulcers
- chronic pressure ulcers
- diabetic foot ulcers
- soft tissue injuries
- venous stasis ulcers
12 Active Policies
UHC-POL-electrical-stimulation-electromagnetic-therapy-wounds — Electromagnetic Therapy for Wounds
AETNA-CPB-0235 — Plantar Fasciitis Treatments
ANTHEM-DME.00011 — DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
UMR-POL-UMR-electrical-stimulation-electromagnetic-therapy-wounds — Electromagnetic Therapy for Wounds
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