Medical Policy

Effective Date:09/21/2004	Title:Intradiscal Electrothermal Therapy (IDET)
Revision Date:01/04/2007	Document:BI075:00
CPT Code(s):22526, 22527
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above Revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. Intradiscal Electrothermal Therapy (IDET) is a treatment for back pain which has not yet reached the status as being established and accepted treatment. It is considered to be Experimental/Investigational and is not covered.
Medical Statement
QualChoice finds IDET to be experimental/investigational, and not covered. Aetna, the Blue Cross/Blue Shield technical assessment, and Hayes (C) all rank it as experimental/investigational. Intradiscal Electrothermal Therapy (IDET) is used to ameliorate localized back pain that is discogenic in nature. It is not effective for radiculopathy. There is some evidence to suggest that it may produce favorable results. The difference between IDET and a sham procedure was statistically significant but not clinically convincing in the one single-center blinded, controlled study done. The longest follow-up interval published in the literature to date is 2 years, which is clearly too short to allow adequate evaluation of long-term effectiveness. Codes Used In This BI: 22526 Intradiscal Electrothermal therapy, one interspace 22527 Each additional interspace
Limits
Intentially left empty
Reference
Hayes: Intradiscal Electrothermal Therapy; May 2003 http://www.bcbs.com/tec/vol18/18_19.html http://www.aetna.com/cpb/data/CPBA0016.html Pauza KJ, Howell S, Dreyfuss P, et al. A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain. Spine J. 2004;4(1):27-35.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.