mp-073 - Medical Policies - Florida
Interferential Stimulator/Stimulation Devices
Policy Number: MP-073
Latest Review Date: June 2019
Policy Grade: B
Description of Procedure or Service:
Interferential current stimulation (IFS) is a type of electrical stimulation used to reduce pain. The technique has been proposed to decrease pain and increase function in patients with osteoarthritis and to treat other conditions such as constipation, irritable bowel syndrome, dyspepsia, and spasticity.
Interferential current stimulation (IFS) is a type of electrical stimulation that has been investigated as a technique to reduce pain, improve function and range of motion, and treat gastrointestinal disorders.
IFS uses paired electrodes of 2 independent circuits carrying high-frequency and medium-frequency alternating currents. The superficial electrodes are aligned on the skin around the affected area. It is believed that IFS permeates the tissues more effectively and with less unwanted stimulation of cutaneous nerves, is more comfortable than transcutaneous electrical nerve stimulation. There are no standardized protocols for the use of IFS; IFS may vary by the frequency of stimulation, the pulse duration, treatment time, and electrode-placement technique.
The IFS or IFS Sequential Stimulator unit for home use is considered not medically necessary and investigational.
The most recent literature was reviewed through April 09, 2019. Following is a summary of the key literature to date.
Evidence reviews assess the clinical evidence to determine whether the use of a technology improves the net health outcome. Broadly defined, health outcomes are the length of life, quality of life, and ability to function-including benefits and harms. Every clinical condition has specific outcomes that are important to patients and managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.
To assess whether the evidence is sufficient to draw conclusions about the net health outcome of a technology, 2 domains are examined: the relevance, and quality and credibility. To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. RCTs are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.
RCTs with placebo control are extremely important to assess treatments of painful conditions, due to the expected placebo effect, the subjective nature of pain assessment in general, and the variable natural history of pain that often responds to conservative care. Therefore, to establish whether an intervention for pain is effective, a placebo comparison is needed.
Clinical Context and Therapy Purpose
The purpose of using interferential current stimulation (IFS) in patients who have musculoskeletal conditions is to provide a treatment option that is an alternative to or an improvement on existing therapies.
The question addressed in this evidence review is: Does use of IFS improve health outcomes for those with musculoskeletal conditions?
The following PICOTS were used to select literature to inform this review.
The relevant population of interest is individuals with musculoskeletal conditions.
The therapy being considered is IFS.
The following therapies are currently being used: physical therapy, medication, and other types of electrical stimulation.
The specific outcomes of interest are pain control, increased functional capacity, and improved quality of life. IFS would be used as adjunctive treatment with observed effects to be expected within 6 months.
Two placebo controlled trials were included in the Fuentes meta-analysis, one of which (Defrin et al, 2005) was also included in the Zeng meta-analysis. The trial by Defrin included a total of 62 patients with osteoarthritic knee pain. Patients were randomly assigned to 1 of 6 groups (there were 4 active treatment groups and 2 control groups, sham and non-treated). Acute pre- versus post-treatment reductions in pain were found in all active groups but not in either control group. Stimulation resulted in a modest pretreatment elevation of pain threshold over the 4 weeks of the study. In 1987, Taylor et al randomly assigned 40 patients with temporomandibular joint syndrome or myofascial pain syndrome to undergo either active or placebo interferential therapy. The principal outcomes were pain assessed by a questionnaire, as well as range of motion. There were no statistically significant differences in the outcomes between the 2 groups.
In 2010, Fuentes et al published a systematic review and meta-analysis of studies evaluating the effectiveness of IFS for treating musculoskeletal pain. A total of 20 studies met the following inclusion criteria: randomized controlled trial (RCT); included adults diagnosed with a painful musculoskeletal condition (e.g. knee, back, joint, shoulder, or osteoarthritic pain); compared IFS alone or as a co-intervention to placebo; no treatment or an alternative intervention; and assessed pain on a numeric scale. Fourteen of the trials reported data that could be included in a pooled analysis. Interferential stimulation as a stand-alone intervention was not found to be more effective than placebo or an alternative intervention. For example, a pooled analysis of 2 studies comparing IFC alone and placebo did not find a statistically significant difference in pain intensity at discharge; the pooled mean difference (MD) was 1.17 (95% confidence interval [CI]:-1.70 to 4.05). In addition, a pooled analysis of two studies comparing IFC alone and an alternative intervention (e.g., traction or massage) did not find a significant difference in pain intensity at discharge; the pooled MD was -0.16( 95% CI: -0.62 to 0.31). Moreover, in a pooled analysis of 5 studies comparing IFC as a co-intervention to a placebo group, there was a non-significant finding (MD=1.60, 95% CI: -0.13 to 3.34; p=0.07). The meta-analysis found IFC plus another intervention to be superior to a control group (e.g., no-treatment). A pooled analysis of 3 studies found an MD of 2.45 (95% CI: 1.69 to 3.22; p<0.001). The latter analysis is limited in that the specific effects of IFC versus the co-intervention cannot be determined, and it does not control for potential placebo effects.
Two other RCTs, both published in 2012, were included in the Zeng meta-analysis. One found significantly better outcomes with IFS versus placebo while the other did not find significant differences between active and sham interventions. Atamaz et al compared IFS, transcutaneous electrical stimulation (TENS), and shortwave diathermy in 203 patients with knee osteoarthritis. Patients were randomized to 1 of 6 groups, 3 with active treatment and 3 with sham treatment. The primary outcome was a 0 to 100 visual analog scale (VAS) assessing knee pain. Other outcomes included range of motion, time to walk 15 meters, paracetamol intake, the Nottingham Health Profile (NHP) and the Western Ontario and McMaster University Osteoarthritis Index (WOMAC). At the 1-, 3-, and 6-month follow-ups, there was not a statistically significant difference among the 6 groups in the VAS pain score, the WOMAC pain score or the NHP pain score. Moreover, the WOMAC function score, time to walk 15 meters, and the NHP physical mobility score did not differ significantly among groups at any of the follow-up assessments. At the 1-month follow-up, paracetamol intake was significantly lower in the IFS group than the TENS group.
A 2015 network meta-analysis by Zeng et al identified 27 RCTs on 5 types of electrical stimulation therapies used to treat pain in patients with knee osteoarthritis. Zeng found that IFS was significantly more effective than control interventions for pain relief (standardized mean difference [SMD], 2.06; 95% credible interval [CrI], 1.10 to 3.19) and pain intensity (SMD = -0.92; 95% CrI, -1.72 to -0.05). The validity of these conclusions is uncertain due to the limitations of network meta-analysis which used indirect comparisons to make conclusions. A further limitation of this analysis is that the findings of placebo-controlled studies were not reported separately; rather, they were pooled in analysis of usual care comparators.
Gundog et al (2012) randomly assigned 60 patients with knee osteoarthritis to 1 of 4 groups; 3 IFS groups at frequencies of 40 Hz, 100 Hz, and 180 Hz, and sham IFS. The primary outcome was pain intensity assessed by the WOMAC. Mean WOMAC scores 1 month after treatment were 7.2 in the 40-Hz group, 6.7 in the 100-Hz group, 7.8 in the 180-Hz group, and 16.1 in the sham IFS group (p<0.05 vs active treatment groups) . Secondary outcomes (e.g., VAS score) also showed significantly higher benefit in the active treatment groups compared to the sham IFS group. The number of patients assigned to each group and patient follow-up rates were not reported.
In addition to the placebo-controlled trials, several RCTs have compared IFS to another active intervention or to usual care. However, studies with active comparators, as well as those with usual care control groups may be subject to the placebo effect. Receiving an older or known, rather than a novel, intervention, may elicit a placebo response.
Section Summary: Musculoskeletal Conditions
Placebo-controlled RCTs of IFS for treating musculoskeletal pain and impaired function have mostly found that it does not significantly improve outcomes. A meta-analysis limited to placebo-controlled trials also did not find a significant benefit of IFS for treating pain and function. RCTs with usual care or active treatment comparisons may be subject to the placebo effect.
Clinical Context and Therapy Purpose
The purpose of using IFS in patients who have gastrointestinal disorders (e.g., constipation, irritable bowel syndrome, and dyspepsia) is to provide a treatment option that is an alternative to or an improvement on existing therapies.
The question addressed in this evidence review is: Does use of IFS improve health outcomes for those with gastrointestinal disorders?
The following PICOTS were used to select literature to inform this review.
The relevant population of interest is individuals with a gastrointestinal disorder such as constipation, irritable bowel syndrome, or dyspepsia.
The therapy being considered is IFS.
The following therapies are currently being used: dietary changes, medication, and other types of electrical stimulation.
The specific outcomes of interest are pain control, increased functional capacity, and improved quality of life. Safety and efficacy of IFS would be evaluated at one month following a 4 week treatment.
Several RCTs evaluating IFS for treating children with constipation and/or other lower gastrointestinal symptoms were identified. The RCTs had small sample sizes and did not consistently find a benefit of interferential stimulation. For example, in 2012, Kajbafzadeh and colleagues in Iran randomized 30 children with intractable constipation to receive IFS or sham stimulation. Children ranged in age from 3 to 12 years-old, and all had failed 6 months of conventional therapy (e.g., dietary changes and laxatives). Patients received fifteen 20-minute sessions, 3 times a week over 5 weeks. Over 6 months, the mean frequency of defecation increased from 2.5 times per week to 4.7 times per week in the treatment group and from 2.8 times per week to 2.9 times per week in the control group. The mean pain during defecation score decreased from 0.35 to 0.20 in the treatment group and from 0.29 to 0.22 in the control group. The authors reported that there was a statistically significant difference between groups in constipation symptoms.
Another RCT was published by Clarke et al in 2009; the study was conducted in Australia. Thirty-three children with slow transit constipation (mean age, 12 years) were randomized to receive IFS or sham treatment. They received twelve 20-minute sessions over 4 weeks. The primary outcome was health-related quality of life and the main instrument used was the Pediatric Quality of Life Inventory (PedsQL). The authors only reported within-group changes; they did not compare the treatment and control groups. There was not a statistically significant change in QOL, as perceived by the parent in either the active or sham treatment group. The mean parentally perceived QOL scores changed from 70.3 to 70.1 in the active treatment group and from 69.8 to 70.2 in the control group. There was also no significant difference in QOL, as perceived by the child after sham treatment. The score on the PedQL group as perceived by the child, did increase significantly in the active treatment group (mean of 72.9 pre-treatment and 81.1 post-treatment, p=0.005).
Irritable Bowel Disease
An RCT with adults was published in 2012 by Coban and colleagues in Turkey. The authors randomized 67 individuals with irritable bowel syndrome to active or placebo interferential current simulation (IFS). Patients with functional dyspepsia were excluded. Patients received a total of four 15- minute sessions over 4 weeks. Fifty-eight of 67 (87%) patients completed the study. One month after treatment, primary outcomes measures did not differ significantly between the treatment and control groups. Treatment response was defined as more than a 50% improvement in symptoms. For the symptom of abdominal discomfort, for example, the response rate was 68% in the treatment group and 44% in the control group. For bloating and discomfort, the response rate was 48% in the treatment group and 46% in the placebo group. Using a visual analogue scale (VAS) measure, 72% of the treatment group and 69% of the control group reported improvement in abdominal discomfort.
One RCT, by Koklu et al (2010) in Turkey, was identified that evaluated interferential current stimulation for treating dyspepsia. The study randomized adults to active IFS (n=25) or sham treatment (n=25); patients were unaware of treatment allocation. There were 12 treatment sessions over 4 weeks; each session lasted 15 minutes. A total of 44 of 50 (88%) randomized patients completed the therapy session and follow-up questionnaires at 2 and 4 weeks. The authors did not specify primary outcome variables; they measured the frequency of 10 gastrointestinal symptoms. In an intention-to-treat (ITT) analysis at four weeks, IFS was superior to placebo for the symptoms of early satiation and heartburn, but not for the other eight symptoms. For example, before treatment, 16 of 25 (64%) patients in each group reported experiencing heartburn. At 4 weeks, 9 patients (36%) in the treatment group and 13 patients (52%) in the sham group reported heartburn; p=0.02. Among symptoms that did not differ at follow-up between groups, 24 of 25 patients (96%) in each group reported epigastric discomfort before treatment. In the ITT analysis at four weeks, 5 of 25 patients (20%) in the treatment group and 6 of 25 (24%) patients in the placebo group reported epigastric discomfort.
Section Summary: Gastrointestinal Disorders
IFS has been tested for a variety of gastrointestinal (GI) conditions, with a small number of trials completed for each condition. The results of these trials are mixed, with some reporting benefit and others reporting no benefit. This body of evidence is inconclusive to determine whether IFS is an efficacious treatment for GI conditions.
Clinical Context and Therapy Purpose
The purpose of using IFS in patients who have poststroke spasticity is to provide a treatment option that is an alternative to or an improvement on existing therapies.
The question addressed in this evidence review is: Does use of IFS improve health outcomes for those with poststroke spasticity?
The following PICOTS were used to select literature to inform this review.
The relevant population of interest is individuals with poststroke spasticity.
The therapy being considered is IFS.
The following therapy is currently being used: standard stroke rehabilitation.
The specific outcomes of interest are improved function and QOL. Effect of IFS would be assessed one hour after a single treatment.
Randomized Controlled Trials
A single-blind RCT evaluating IFS as a treatment of chronic stroke was published by Suh et al (2014). Forty-two inpatient stroke patients with plantar flex or spasticity were randomized to a single 60-minute session with IFS or placebo IFS treatment following 30 minutes of standard rehabilitation. In the placebo treatment, electrodes were attached; however, the current was not applied. Outcomes were measured immediately before and one1 hour after the intervention. The primary outcomes were gastrocnemius spasticity (measured on a 0 to 5 Modified Ashworth Scale) and 2 balance-related measures: the Functional Reach Test and the Berg Balance Scale. Also, gait speed was measured using a 10-meter walk test, and gait function was assessed with the Timed Up & Go Test. The IFS group performed significantly better than the placebo group on all outcomes (p <0.05 for each comparison). For example, the mean (standard deviation) difference in Modified Ashworth Scale score was 1.55 (0.76) in the IFS group and 0.40 (0.50) in the placebo group. A major limitation of the trial was that outcomes were only measured 1 hour after the intervention and no data were available on longer term impacts of the intervention.
Section Summary: Poststroke Spasticity
Data from 1 small RCT with very short follow-up provides insufficient evidence on the impact of IFS on health outcomes in patients with post-stroke spasticity.
Summary of Evidence
For individuals who have musculoskeletal conditions who receive IFS, the evidence includes randomized controlled trials (RCTs) and meta-analyses. Relevant outcomes are symptoms, functional outcomes, quality of life, medication use, and treatment-related morbidity. Placebo-controlled RCTs of IFS for treating musculoskeletal pain and impaired function have mostly found that it does not significantly improve outcomes and a meta-analysis of placebo-controlled trials did not find a significant benefit of IFS for decreasing pain or improving function. The evidence is insufficient to determine the effects of the technology on health outcomes.
For individuals who have gastrointestinal disorders who receive IFS, the evidence includes RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, medication use and treatment-related morbidity. IFS has been tested for a variety of gastrointestinal conditions, with a small number of trials completed for each condition. Trials results are mixed, with some reporting benefit and others not. This body of evidence is inconclusive on whether IFS is an efficacious treatment for gastrointestinal conditions. The evidence is insufficient to determine the effects of the technology on health outcomes.
For individuals who have poststroke spasticity who receive IFS, the evidence includes 1 RCT. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The RCT has a small sample size and very short follow-up (immediately posttreatment). The evidence is insufficient to determine the effects of the technology on health outcomes.
Practice Guidelines, and Position Statements
American College of Physicians and the American Pain Society
Clinical practice guidelines from the American College of Physicians and the American Pain Society, published in 2009, concluded that there was insufficient evidence to recommend interferential stimulation for the treatment of low back pain.
American College of Occupational and Environmental Medicine
The American College of Occupational and Environmental Medicine published several relevant guidelines. For shoulder disorders, guidelines found the evidence on IFS to be insufficient and, depending on the specific disorder, either did not recommend IFS or were neutral on whether to recommend it. For low back disorders, guidelines found the evidence on IFS to be insufficient and did not recommend it. The sole exception was that IFS could be considered as an option on a limited basis for acute low back pain with or without radicular pain. For knee disorders, guidelines recommended IFS for postoperative anterior cruciate ligament reconstruction, meniscectomy, and knee chondroplasty immediately postoperatively in the elderly. This was a level C recommendation.
U.S. Preventive Services Task Force Recommendations
Interferential current therapy (IF), interferential stimulation (IF), interferential stimulator, transcutaneous electrical nerve stimulation (TENS), sequential stimulator, RS-4i Sequential stimulator
Approved by Governing Bodies:
A number of IFS devices have been cleared for marketing by the U.S. Food and Drug Administration through the 510(k) process, including the Medstar™ 100 (MedNet Services) and the RS-4i® (RS Medical). IFS may be included in multimodal electrotherapy devices such as transcutaneous electrical nerve stimulation and functional electrostimulation.
Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.
ITS: Home Policy provisions apply
FEP contracts: Special benefit consideration may apply. Refer to member’s benefit plan. FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.
97014 Application of a modality to 1 or more areas; electrical stimulation (unattended)
97032 Application of modality or one or more areas; electrical stimulation (manual), each 15 minutes (attended)
G0283 Electrical stimulation (unattended, to 1 or more areas for indications other than wound care, as part of a therapy plan of care
S8130 Interferential current stimulator, 2 channel
S8131 Interferential current stimulator, 4 channel
64550 Application of surface (transcutaneous) neurostimulator (e.g. TENS unit) (Deleted 12/31/18)
Albornoz-Cabello M, Maya-Martin J, Dominguez-Maldonado G, et al. Effect of interferential current therapy on pain perception and disability level in subjects with chronic low back pain: A randomized controlled trial. Clin Rehabil. Mar 14 2016.
American College of Occupational and Environmental Medicine. (ACOEM) Chronic pain. Available online at: www.guidelines.gov.
American College of Occupational and Environmental Medicine (ACOEM). Shoulder Disorders. Available online at: www.guideline.gov Accessed May 15, 2016.
American College of Occupational and Environmental Medicine (ACOEM). Low Back Disorders. Available online at: www.guideline.gov. Accessed May 15, 2016.
American College of Occupational and Environmental Medicine (ACOEM). Knee Disorders. Available online at: www.guideline.gov. Accessed May 15, 2016.
Atamaz FC, Durmaz B, Baydar M et al. Comparison of the efficacy of transcutaneous electrical nerve stimulation, interferential currents, and shortwave diathermy in knee osteoarthritis: a double-blind, randomized, controlled, multicenter study. Arch Phys Med Rehabil 2012; 93(5):748-5
Awbrey, Brian J. Reduction of postoperative knee arthroscopy pain and swelling by patient-controlled interferential therapy. Massachusetts General Hospital, 1994.
Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Medicine 2007; 147(7): 478-491.
Chou R, Atlas SJ, Stanos SP, et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). May 1 2009; 34(10):1078-1093.
Clarke MC, Chase JW, Gibb S et al. Improvement of quality of life in children with slow transit constipation after treatment with transcutaneous electrical stimulation. J Pediatr Surg 2009; 44(6):1268-1272; discussion 1272.
Coban S, Akbal E, Koklu S et al. Clinical trial: transcutaneous interferential electrical stimulation in individuals with irritable bowel syndrome - a prospective double-blind randomized study. Digestion 2012; 86(2):86-93.
Correa JB, Costa LO, de Oliveira NT et al. Effects of the carrier frequency of interferential current on pain modulation in patients with chronic nonspecific low back pain: a protocol of a randomized controlled trial. BMC Musculoskelet Disord 2013; 14:195.
Davis, Samuel. A versatile electrotherapy method—Interferential current therapy. Physical Therapy Products, 1994.
Defrin R, Ariel E and Peretz C. Segmental noxious versus innocuous electrical stimulation for chronic pain relief and the effect of fading sensation during treatment. Pain, May 2005; 115(1-2): 152-160.
Dissanayaka TD, Pallegama RW, Suraweera HJ, et al. Comparison of the effectiveness of transcutaneous electrical nerve stimulation and interferential therapy on the upper trapezius in myofascial pain syndrome: a randomized controlled study. Am J Phys Med Rehabil. Mar 4 2016.
Excellus Health Plan, Inc. Electrical Stimulation. Medical Policy, March 2002.
Facci LM, Nowotny JP, Tormem F et al. Effects of transcutaneous electrical nerve stimulation (TENS) an interferential currents (IFC) in patients with nonspecific chronic low back pain: randomized controlled trial. Sao Paulo Med J 2011; 129(4):206-16.
Fuentes JP, Armijo Olivo S, Magee DJ et al. Effectiveness of interferential current therapy in the management of musculoskeletal pain: a systematic review and meta-analysis. Phys Ther 2010; 90(9):1219-38.
Gundog M, Atamaz F, Kanyilmaz S, et al. Interferential current therapy in patients with knee osteoarthritis: comparison of the effectiveness of different amplitude-modulated frequencies. Am J Phys Med Rehabil. Feb 2012; 91(2):107-113.
Hou CR, Tsai LC, Cheng KF et al. Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Arch Phys Med Rehabil 2002; 83(10):1406-14.
Hurley DA, Minder PM, McDonough SM et al. Interferential therapy electrode placement technique in acute low back pain: a preliminary investigation. Arch Phys Med Rehabil 2001; 82(4): 485-93.
Johnson MI. A single-blind placebo-controlled investigation into the analgesic effects of interferential currents on experimentally induced ischemic pain in healthy subjects. Clinical Physiology and Functional Imaging, May 2002; 22(3): 187-96.
Johnson MI. An investigation into the analgesic effects of interferential currents and transcutaneous electrical nerve stimulation on experimentally induced ischemic pain in otherwise pain-free volunteers. Physical Therapy; March 2003; 83(3): 208-23.
Kajbafzadeh AM, Sharifi-Rad L, Nejat F et al. Transcutaneous interferential electrical stimulation for management of neurogenic bowel dysfunction in children with myelomeningocele. Int J Colorectal Dis 2012; 27(4):453-8.
Koca I, Boyaci A, Tutoglu A, et al. Assessment of the effectiveness of interferential current therapy and TENS in the management of carpal tunnel syndrome: a randomized controlled study. Rheumatol Int. Apr 12 2014.
Koca I, Boyaci A, Tutoglu A, et al. Assessment of the effectiveness of interferential current therapy and TENS in the management of carpal tunnel syndrome: a randomized controlled study. Rheumatol Int. Dec 2014; 34(12):1639-1645.
Koklu S, Koklu G, Ozguclu E et al. Clinical trial: interferential electric stimulation in functional dyspepsia patients - a prospective randomized study. Aliment Pharmacol Ther 2010; 31(9):961-968.
Lara-Palomo IC, Aguilar-Ferrandiz ME, Mataran-Penarrocha GA, et al. Short-term effects of interferential current electro-massage in adults with chronic non-specific low back pain: a randomized controlled trial. Clin Rehabil. May 2013; 27(5):439-449.
Latzanich, Carol M., et al. Interferential current therapy for post-operative pain management. Contemporary Podiatric Physician, November 1993.
Minder PM. Interferential therapy: Lack of effect upon experimentally induced delayed onset muscle soreness. Clinical Physiology and Functional Imaging, September 2002; 22(5): 339-47.
Poitras S and Brosseau L. Evidence-informed management of chronic low back pain with transcutaneous electrical nerve stimulation, interferential current, electrical muscle stimulation, ultrasound, and thermotherapy. Spine J 2008; 8(1): 226-233.
Suh HR, Han HC, Cho HY. Immediate therapeutic effect of interferential current therapy on spasticity, balance, and gait function in chronic stroke patients: a randomized control trial. Clin Rehabil. Sep 2014; 28(9):885-891.
The Regence Group. Electrical Stimulation Devices. Medical Policy, March 2002.
Taylor K, Newton RA, Personius WJ et al. Effects of interferential current stimulation for treatment of subjects with recurrent jaw pain. Phys Ther 1987; 67(3):346-50.
Van der Heijden GJ, Leffers P, Wolters PJ et al. No effect of bipolar interferential electrotherapy and pulsed ultrasound for soft tissue disorders: a randomized controlled trial. Ann Rheum Dis 1999; 58(9):530-50.
Werners R, Pynsent PB, Bulstrode CJ. Randomized trial comparing interferential therapy with motorized lumbar traction and massage in the management of low back pain in a primary care setting. Spine 1999; 24(15):1579-84.
Zambito A, Bianchini D, Gatti D, et al. Interferential and horizontal therapies in chronic low back pain due to multiple vertebral fractures: A randomized, double blind, clinical study. Osteoporos Int 2007; 18(11): 1541-1545.
Zeng C, Li H, Yang T, et al. Electrical stimulation for pain relief in knee osteoarthritis: systematic review and network meta-analysis. Osteoarthritis Cartilage. Feb 2015; 23(2):189-202.
Medical Policy Group, October 2002
Medical Policy Administration Committee, October 2002
Available for comment December 18, 2002-February 3, 2003
Medical Policy Group, November 2004 (4)
Medical Policy Group, June 2005 (3)
Medical Review Committee, June 2005 (2)
Medical Policy Administration Committee, July 2005
Available for comment July 28-September 10, 2005
Medical Policy Group, November 2006 (1)
Medical Policy Group, November 2008 (1)
Medical Policy Group, September 2010 (1)
Medical Policy Administration Committee, September 2010
Available for comment September 14-October 28, 2010
Medical Policy Group, November 2010
Medical Policy Group, December 2011 (3): 2012 Code Updates – Added Codes S8130 & S8131
Medical Policy Group, March 2012 (3): 2011 Literature Update, updated Key Points and References
Medical Policy Panel, December 2012
Medical Policy Group, December 2012 (3): 2012 Literature Update, updated Key Points and References. Policy statement remains unchanged
Medical Policy Panel, December 2013
Medical Policy Group, January 2014 (3): 2013 Updates to Key Points and References; no change in policy statement; removed policy statements greater than 3 years old
Medical Policy Panel, December 2014
Medical Policy Group, January 2015 (3): 2014 Updates to Key Points and References, no change in policy statement
Medical Policy Panel, June 2016
Medical Policy Group, July 2016 (6): Updates to Description of Procedure or Services, Policy, Key Points, Summary, Approved by Governing Bodies and References, removed 2012 previous coding; no change in policy intent.
Medical Policy Panel, September 2017
Medical Policy Group, September 2017 (6): Updates to Key Points and Coding.
Medical Policy Group, December 2017: Annual Coding Update 2018. Updated verbiage for revised CPT code 64550.
Medical Policy Panel, June 2018
Medical Policy Group, June 2018 (6): Updates to Key Points, Practice Guidelines, Governing Bodies and References.
Medical Policy Group, December 2018: 2019 Annual Coding Update. Moved CPT code from Current coding section to Previous coding. Created Previous coding section to include code 64550.
Medical Policy Panel, June 2019
Medical Policy Group, June 2019 (6): Updates to Key Points.
This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.
The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.
As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.
The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:
1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.
Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:
1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.