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Date Printed: October 21, 2017: 11:34 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-61000-26

Original Effective Date: 08/15/02

Reviewed: 04/30/09

Revised: 11/01/15

Subject: Sympathetic Therapy for the Treatment of Pain

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates  

DESCRIPTION:

Sympathetic therapy is a non-invasive treatment alternative for symptomatic relief of chronic intractable pain. Sympathetic therapy describes a type of electrical stimulation of the peripheral nerves. Sympathetic therapy stimulates the sympathetic nervous system in an effort to "normalize" the autonomic nervous system and alleviate chronic pain. Sympathetic therapy is not designed to treat local pain, but is designed to induce a systemic effect on sympathetically induced pain. Sympathetic therapy uses 4 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. An electrical current is induced with beat frequencies between 0 and 1000Hz. Treatment may include daily 1-hour treatments in the physician's office, followed by home treatments if the initial treatment is effective.

The Dynatron STS (a clinical unit) and the Dynatron STS Rx (a home unit) are devices that deliver sympathetic therapy. These devices received US Food and Drug Administration (FDA) approval in March 2001. 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." A software program is included with the Dynatron unit to help physicians with electrode placement and to record patient progress. Daily therapy sessions are needed to establish effectiveness of the treatment and to ascertain the most effective protocol for individual patients (20 or more sessions may be needed to complete the therapy). Each treatment session lasts about 60 minutes. If the patient responds to treatment and the optimal protocol has been established, a home Dynatron unit may be prescribed to facilitate treatments over an extended period of time and, in most cases, indefinitely. The patient may return to the clinic periodically for a follow-up visit to adjust the protocol or receive additional guidance in administering home therapy.

There are no published studies demonstrating the effectiveness of sympathetic therapy in the management of patients with chronic pain. Randomized controlled trials are needed to determine the clinical benefits of sympathetic therapy in the management of chronic pain.

POSITION STATEMENT:

Sympathetic therapy is considered experimental or investigational, as there is insufficient clinical evidence to support the use of sympathetic therapy for the treatment of pain. There are no published studies in the peer-reviewed literature demonstrating the effectiveness of sympathetic therapy in the management of patients with chronic intractable pain.

BILLING/CODING INFORMATION:

CPT/HCPCS Coding:

There is no specific CPT or HCPCS code that describes sympathetic therapy.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report sympathetic therapy:

Note: The use of specific product names is illustrative only. It is not intended to be a recommendation of
one product over another, and is not intended to represent a complete listing of all products available.

Dynatron

REFERENCES:

  1. Blue Cross Blue Shield Association Medical Policy Reference Manual. 1.04.03 Sympathetic Therapy for the Treatment of Pain, 03/13/08.
  2. ClinicalTrials.gov, Electrical Stimulation After Total Knee Arthroplasty, sponsored by National Institute of child Health and Human Development, accessed on 05/14/07.
  3. Dynatronic Sympathetic Therapy (Dynatron STSÔ & Dynatron STS Rx [home unit]): Revolutionary Breakthrough in the Treatment of Chronic Pain.
  4. Food and Drug Administration (FDA). Dynatron® STS™, Dynatron® STS™ Rx 510(k) summary. 05/15/01.
  5. Guido EH. Effects of sympathetic therapy on chronic pain in peripheral neuropathy subjects. Am J Pain Mgmt 2002; 12:31-34.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/30/09.

GUIDELINE UPDATE INFORMATION:

08/15/02

New Medical Coverage Guideline.

08/15/03

Annual review; no change in coverage statement – investigational.

07/15/04

Review of guideline with no changes; maintain investigational status.

08/15/05

Review and revision of guideline; consisting of updated references.

07/15/06

Review and revision of guideline consisting of updated references and maintaining investigational statement.

06/17/07

Annual review; investigational status maintained; guideline reformatted; references updated.

05/15/08

Review and revision of guideline consisting of updated references.

05/15/09

Scheduled review; no change in position statement.

05/11/14

Revision: Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: October 21, 2017: 11:34 AM