ELECTRIC CURRENT THERAPY (IONTOPHORESIS) HS-237

(1)

ELECTRIC CURRENT THERAPY (IONTOPHORESIS) HS-237

Clinical Coverage Guideline page 1 Original Effective Date: 1/9/2014 - Revised: 4/3/2014, 4/2/2015, 6/2/2016, 12/7/2017, 2/1/2018

Care1st Health Plan Arizona, Inc.

Easy Choice Health Plan Harmony Health Plan of Illinois Missouri Care

‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona

OneCare (Care1st Health Plan Arizona, Inc.) Staywell of Florida

WellCare (Arkansas, Connecticut, Florida, Georgia, Illinois, Kentucky, Louisiana, Mississippi, Nebraska, New Jersey, New York, South Carolina, Tennessee, Texas)

WellCare Prescription Insurance

Electric Current Therapy (Iontophoresis)

Policy Number: HS-237

Original Effective Date: 1/9/2014

Revised Date(s): 4/3/2014; 4/2/2015; 6/2/2016;

12/7/2017; 2/1/2018

APPLICATION STATEMENT

The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any.

DISCLAIMER

The Clinical Coverage Guideline (CCG) is intended to supplement certain standard WellCare benefit plans and aid in administering benefits. Federal and state law, contract language, etc. take precedence over the CCG (e.g., Centers for Medicare and Medicaid Services [CMS] National Coverage Determinations [NCDs], Local Coverage Determinations [LCDs] or other published documents). The terms of a member’s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member’s benefit plan may contain specific exclusions related to the topic addressed in this CCG. Additionally, CCGs relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. Providers are responsible for the treatment and recommendations provided to the member. The application of the CCG is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. All links are current at time of approval by the Medical Policy Committee (MPC) and are subject to change prior to the annual review date. Lines of business (LOB) are subject to change without notice; current LOBs can be found at www.wellcare.com. All guidelines can be found at this site as well but selecting the Provider tab, then “Tools” and “Clinical Guidelines”.

BACKGROUND

Electric Current Therapy (or Iontophoresis) is a method of transdermal local drug delivery using electrical current. A charged ionic drug is placed on the skin with an electrode of the same charge, allowing direct current to drive the drug into the skin.

(2)

ELECTRIC CURRENT THERAPY (IONTOPHORESIS) HS-237

POSITION STATEMENT Applicable To:

Medicaid – All Markets Medicare – All Markets Exclusions

Use of iontophoresis is considered experimental and investigational due to insufficient evidence related to efficacy. Indications may include, but are not limited to:

 Administration of acetic acid for treating epicondylitis

 Administration of acetylcholine and sodium nitroprusside for assessing risk of development and progression of cardiovascular disease.

 Administration of non-steroidal anti-inflammatory drugs or corticosteroids for treating musculoskeletal disorders (e.g., patella-femoral pain syndrome).

 Administration of verapamil for treating Peyronie's disease.

 Administration of vitamin C for treating melasma.

Coverage

Use of iontophoresis is considered medically necessary at least one of the following is met:

1. When part of physical or occupational therapy and is combined with another procedure code that extends treatment time to at least 8 minutes to qualify under the 8-minute rule; OR,

2. Delivery of local anesthetic before emergent skin puncture or dermatological procedures to reduce pain associated with these procedures; OR,

3. Intractable, disabling primary focal hyperhidrosis when all of the following are met:

 Member is unresponsive or unable to tolerate pharmacotherapy prescribed for excessive sweating (e.g., anti-cholinergics, beta-blockers, or benzodiazapines); AND,

 Topical aluminum chloride or other extra-strength anti-perspirants are ineffective or result in a severe rash.

AND EITHER,

 Documentation in the medical record of significant disruption of professional and/or social life has occurred because of excessive sweating, including inability to perform age-appropriate activities of daily living; OR,

 Condition is causing persistent or chronic cutaneous conditions (e.g., skin maceration, dermatitis, fungal infections, secondary microbial infections).

OR,

4. Iontophoretic administration of fentanyl for patient-controlled analgesia of acute post-operative pain.

OR,

5. Sweat test by pilocarpine iontophoresis for the diagnosis of cystic fibrosis.

CODING

Botulinum Toxin Covered CPT Codes

(3)

ELECTRIC CURRENT THERAPY (IONTOPHORESIS) HS-237

64650 Chemodenervation of eccrine glands; both axillae

64653 Chemodenervation of eccrine glands; other area(s) (e.g., scalp, face, neck), per day 97033 Application of a modality to 1 or more areas; Iontophoresis, each 15 minutes

Covered HCPCS Codes

E1399 Durable medical equipment, miscellaneous [when specified as iontophoresis device for home use]

J0585 Injection, onabotulinumtoxinA, 1 unit J0586 Injection, abobotulinumtoxinA, 5 units J0587 Injection, rimabotulinumtoxinB, 100 units J0588 Injection, incobotulinumtoxinA, 1 unit

ICD-10 Diagnosis ICD-10-CM draft codes; effective 10/01/2014 L74.510-L74.519 Primary focal hyperhidrosis, axilla (L74.510) L74.52 Secondary focal hyperhidrosis

R61 Generalized hyperhidrosis

When Services are Not Medically Necessary: For the procedure and diagnosis codes listed above when criteria are not met, or when the code describes a procedure indicated in the Position Statement section as not medically necessary.

Sympathectomy Covered CPT Codes

00622 Anesthesia for procedures on thoracic spine and cord; thoracolumbar sympathectomy 32664 Thoracoscopy, surgical; with thoracic sympathectomy

Covered ICD-10 Procedure

01BL3ZZ Excision of thoracic sympathetic nerve, percutaneous approach

01BL4ZZ Excision of thoracic sympathetic nerve, percutaneous endoscopic approach

Covered ICD-10 Diagnosis Codes

L74.510 Primary focal hyperhidrosis, axilla L74.512 Primary focal hyperhidrosis, palms

When services are Not Medically Necessary: For the procedure and diagnosis codes listed above when criteria are not met or for the following diagnoses, or when the code describes a procedure indicated in the Position Statement section as not medically necessary.

L74.511 Primary focal hyperhidrosis, face L74.519 Primary focal hyperhidrosis, unspecified L74.52 Secondary focal hyperhidrosis

When services are Investigational and Not Medically Necessary: For the procedure codes listed above for the following diagnoses, or when the code describes a procedure indicated in the Position Statement section as not medically necessary.

L74.513 Primary focal hyperhidrosis, soles Non-Covered CPT Codes

64520 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) 64818 Sympathectomy, lumbar

64999 Unlisted procedure, nervous system

Non-Covered ICD-10 Procedure Codes

01BN0ZZ Excision of lumbar sympathetic nerve, open approach

01BN3ZZ Excision of lumbar sympathetic nerve, percutaneous approach

(4)

ELECTRIC CURRENT THERAPY (IONTOPHORESIS) HS-237

01BN4ZZ Excision of lumbar sympathetic nerve, percutaneous endoscopic approach

Non-Covered ICD-10 Diagnosis Codes L74.513 Primary focal hyperhidrosis, soles L74.519 Primary focal hyperhidrosis, unspecified L74.52 Secondary focal hyperhidrosis

R61 Generalized hyperhidrosis Non-Covered CPT Codes

15876-15879 Suction assisted lipectomy; head and neck (15876)

17999 Unlisted procedure, skin, mucous membrane and subcutaneous tissue

Non-Covered ICD-10 Procedure Codes

0X040ZZ-0X044ZZ Alteration of right axilla [by approach; includes codes 0X040ZZ, 0X043ZZ, 0X044ZZ]

0X050ZZ-0X054ZZ Alteration of left axilla [by approach; includes codes 0X050ZZ, 0X053ZZ, 0X054ZZ]

Non-Covered ICD-10 Diagnosis Codes

L74.510-L74.519 Primary focal hyperhidrosis, axilla (L74.510) L74.52 Secondary focal hyperhidrosis

Coding information is provided for informational purposes only. The inclusion or omission of a CPT, HCPCS, or ICD-10 code does not imply member coverage or provider reimbursement. Consult the member's benefits that are in place at time of service to determine coverage (or non- coverage) as well as applicable federal / state laws.

REFERENCES

1. Iontophoresis for epicondylitis. Hayes Directory Web site. http://www.hayesinc.com. Published July 9, 2012 (archived September 6, 2013.

Accessed January 24, 2018.

2. Ultrasound-enhanced transcutaneous drug delivery. Hayes Directory Web site. http://www.hayesinc.com. Published July 12, 2011 (archived August 9, 2012). Accessed January 24, 2018.

MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS

Date Action

2/1/2018, 12/7/2017, 5/4/2017, 6/2/2016, 4/2/2015  Approved by MPC. No changes.

4/3/2014  Approved by MPC. Included medically necessary criteria.

1/9/2014  Approved by MPC. New.