Medical Policy
Effective Date:03/01/2016 Title:Non-Contact Non-Thermal Ultrasound Wound Healing
Revision Date: Document:BI500:00
CPT Code(s):97610
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.

1)    QualChoice does not cover low frequency non-contact ultrasound wound therapy because there is insufficient evidence that this therapy is effective.
Medical Statement

1)    Low frequency non-contact ultrasound wound therapy, including but not limited to the Focused Aspiration of Soft Tissue procedure, the MIST Therapy System, the Qoustic Wound Therapy System, and the Sonoca 180/185 Wound Care System, is considered experimental and investigational because its effectiveness has not been established.

 

Codes Used In This BI:

 

97610             Low frequency, non-contact, non-thermal ultrasound
Limits
Intentially left empty
Reference

1)    Cullum N, et al. Ultrasound therapy used for healing venous (varicose) leg ulcers and to improve symptoms.  Cochrane Library, accessed online 4 Jan 2016

2)    Akbari SA, et al.  The effect of therapeutic ultrasound on pressure ulcers.  Cochrane Library, accessed online 4 Jan 2016

3)    Health Quality Ontario.  Management of Chronic Pressure Ulcers.  Ont Health Technol Assess Ser. 2009;9(3): 1-203

4)    Effects of Non-Contact Low Frequency Ultrasound in Healing Venous Leg Ulcers.  NCT01549860.  Accessed from ClinicalTrials.gov on 4 Jan 2016

5)    Michailidis L, et al.  Comparison of healing rate in diabetes-related foot ulcers with low frequency ultrasonic debridement versus non-surgical sharps debridement:  a randomized trial protocol.  Jnl Foot and Ankle Res. 2014, 7:1. 

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.