Clinical UM Guideline
|Subject:||Iontophoresis for Medical Indications|
|Guideline #:||CG-MED-28||Current Effective Date:||04/15/2014|
|Status:||Reviewed||Last Review Date:||02/13/2014|
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. This document addresses the use of iontophoresis as a technique for drug delivery.
Note: Please see the following document for information regarding the use of iontophoresis for hyperhidrosis:
Iontophoresis is considered medically necessary for the administration of local anesthesia prior to a venipuncture or dematologic procedure.
Not Medically Necessary:
The use of iontophoresis is considered not medically necessary for all other indications including, but not limited to, the administration of nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids as treatment for inflammatory musculoskeletal disorders.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|97033||Application of a modality to one or more areas; iontophoresis, each 15 minutes|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2014]|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2014]|
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. Iontophoresis may take advantage of sweat ducts, sebaceous glands, hair follicles, and imperfections in the skin to achieve penetration. Alternatively, electrical potential across the skin could alter its permeability, possibly creating potential-dependent pores in lipid bilayer membranes.
Iontophoresis has been proposed for numerous uses including the delivery of local anesthetic before skin puncture or painful dermal procedures and for local drug delivery for agents including, but not limited to, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids for musculoskeletal inflammatory disorders, or verapamil for the treatment of Peyronie's disease. Overall, the results published in the peer-reviewed medical literature include small randomized, placebo-controlled or comparative trials and non-randomized retrospective studies. The study results, reported as treatment outcome measurements, do not support the iontophoretic application of NSAIDs, corticosteroids, or other drugs for the treatment of carpal tunnel syndrome (Amirjani, 2009; Bakhtiary, 2013; Gurcay, 2012), chronic foot eczema (Tupker, 2013), epicondylitis (Nirschl, 2003), intractable central pain (Vranken, 2005), migraine headache (Pierce, 2010), onychomycosis (Amichai, 2010), plantar fasciitis (Allison, 2006), tendonitis (Leduc, 2003; Neeter, 2003), trapezial-metacarpal joint arthritis (Jain, 2010), or verapamil (with or without dexamethasone) for the treatment of Peyronie's disease (Bennett, 2007; Greenfield, 2007; Mehrsai, 2013).
The U.S. Food and Drug Administration (FDA) has granted 510(k) clearance for a number of iontophoresis devices to "introduce ions of soluble salts or other drugs into the body." The FDA prohibits labeling or promoting their use with specific drugs prior to the FDA having approved the drugs for iontophoretic administration (FDA, 2013).
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications
|Reviewed||02/13/2014||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion and References sections.|
|Reviewed||02/14/2013||MPTAC review. Updated Discussion and References. Removed Index.|
|Reviewed||02/16/2012||MPTAC review. Updated References.|
|Reviewed||02/17/2011||MPTAC review. Updated Discussion, Coding, and References.|
|Reviewed||02/25/2010||MPTAC review. Updated Discussion and References. Removed sections: Place of Service and Discharge Plans.|
|Reviewed||02/26/2009||MPTAC review. Updated References.|
|Reviewed||02/21/2008||MPTAC review. Updated Discussion and References.|
|Revised||03/08/2007||MPTAC review. Clinical Indications revised/clarified. Discussion, References and Coding updated.|
|New||03/23/2006||MPTAC initial document development.|
Last Review Date
|Memo 1192||Iontophoresis for Medical Indications|
|WellPoint Health Networks, Inc.|