CAM 10403

Sympathetic Therapy for the Treatment of Pain

Category:Durable Medical Equipment   Last Reviewed:July 2019
Department(s):Medical Affairs   Next Review:July 2999
Original Date:July 2013    

Description:
Sympathetic therapy describes a type of electrical stimulation of the peripheral nerves that is designed to stimulate the sympathetic nervous system in an effort to "normalize" the autonomic nervous system and alleviate chronic pain. Unlike TENS (transcutaneous electrical nerve stimulation) or interferential electrical stimulation, sympathetic therapy is not designed to treat local pain, but is designed to induce a systemic effect on sympathetically induced pain.

Sympathetic therapy uses four intersecting channels of various frequencies with bilateral electrode placement on the feet, legs, arms and hands. Based on the location of the patient's pain and treatment protocols supplied by the manufacturer, electrodes are placed in various locations on the lower legs and feet or the hands and arms. Electrical current is then induced with beat frequencies between 0 and 1000 Hz. Treatment may include daily one-hour treatments in the physician's office, followed by home treatments, if the initial treatment is effective.

The Dynatron STS device and a companion home device, Dynatron STS Rx (Dynatronics Corporation), are devices that deliver sympathetic therapy. These devices received U.S. Food and Drug Administration (FDA) clearance in March 2001 through a 510(k) process. The FDA-labeled indication is as follows:

"Electrical stimulation delivered by the Dynatron STS and Dynatron STS Rx is indicated for providing symptomatic relief of chronic intractable pain and/or management of post-traumatic or post-surgical pain."

Policy:
Sympathetic therapy is considered INVESTIGATIONAL.

Policy Guidelines 
When sympathetic therapy is administered in the physician's office, CPT code 97014 or 97032 may be used, which describes unattended and attended electrical stimulation therapy, respectively. These CPT codes are not specific for sympathetic therapy, and, thus, when offered in the office or clinic, based on CPT code alone, sympathetic therapy cannot be distinguished from other types of electrical stimulation.

After a successful trial period in the office, home therapy may be recommended, using either a rented or purchased device. There is no HCPCS code that explicitly describes sympathetic therapy, and the manufacturer reports that a nonspecific HCPCS code such as A9900 (miscellaneous DME supply, accessory and/or service component of another HCPCS code) may be used. However, it is possible that a HCPCS code for TENS might be used (e.g., E0730 Transcutaneous electrical nerve stimulation [TENS], four or more leads, for multiple nerve stimulation). 

Benefit Application
BlueCard®/National Account Issues
State or federal mandates (e.g., FEP) may dictate that all FDA-approved devices may not be considered investigational. However, this policy considers specific applications of an FDA-approved device as investigational. Alternatively, FDA-approved devices may be assessed on the basis of their medical necessity.

Rationale:
Ideally, assessment of therapies designed to treat chronic pain should be based on placebo-controlled trials to assess the magnitude of the expected placebo effect and to isolate the contribution of the active treatment. Outcomes of interest might include changes in scores of a visual analog scale (VAS), quality of life measures such as an SF-36, reduction in pain medications, daily activity levels or return to work. However, a MEDLINE search did not identify any studies published in the peer-reviewed literature regarding sympathetic therapy.

An information packet from the manufacturer Dynatronics (Salt Lake City, Utah) (1) includes two articles also referenced in its promotional material. Although these two articles have not been published in the peer-reviewed literature, they are briefly reviewed below.

  1. Sacks and colleagues reported on a retrospective study of 197 patients with chronic pain of various origins, including upper and lower extremity pain and migraine. Some patients reported multiple sites of pain, and each different site of pain was registered as a separate pain complaint, resulting in 227 patient records. Of these, 91 percent reported mild pain relief, with 33 percent reporting complete pain relief. A total of 78 percent reported an increase in their daily living activities by 50 percent or more, and 69 percent reported a decrease in medications. No data were reported regarding the various etiologies of pain, prior treatment including baseline drug requirements, exact treatment protocol, the number of treatments or how pain relief, activities of daily living or other treatment outcomes were evaluated. There was no control group.
  2. Guido reported on the effects of sympathetic therapy in 20 volunteers suffering from chronic pain related to peripheral neuropathy. The treatment protocol varied with the site of pain, i.e., upper versus lower extremity, and could vary from day to day. Patients underwent daily therapy for 28 days. At the end of the study, the mean global VAS scores were significantly reduced, although these data are not presented in a table or figure. There was no control group.

References:

  1. Guido EH. Effects of sympathetic therapy on chronic pain in peripheral neuropathy subjects. Am J Pain Manage 2002; 12(1):31-4.
  2. Work Loss Data Institute. Pain 2006; National Guideline Clearinghouse.

Coding Section

Codes Number Description
CPT 97014 Application of a modality to 1 or more areas; electrical stimulation (unattended)
  97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes (constant attendance)
ICD-9 Procedure    
ICD-9 Diagnosis   Investigational for all diagnosis 
HCPCS A9900 Miscellaneous DME supply, accessory, and/or service component of another HCPCS code may be used
  E0730 Transcutaneous electrical nerve stimulation (TENS) device, 4 or more leads, for multiple nerve stimulationI
ICD-10-CM (effective 10/01/15)   Investigational for all diagnosis  
ICD-10-PCS (effective 10/01/15)  

ICD-10 codes are only used for inpatient services. There is no specific ICD-10-PCS code for this procedure.

Type of Service Durable Medical Equipment  
Place of Service Office, Home  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.  

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

07/08/2019 

Annual review, no change to policy intent. 

07/30/2018 

Annual review, no change to policy intent 

07/31/2017 

Annual review, no changes made. 

07/07/2016 

Annual review, no change to policy intent. 

09/23/2015 

Added ICD-10 verbiage. 

07/09/2015

Annual review, no change to policy intent. Adding coding.

07/08/2014

Annual review, no changes made.


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