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Coverage criteria policies

Spinal cord and implanted peripheral nerve stimulation

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative Process

Prior authorization is required for both the trial insertion and permanent placement of a spinal cord stimulator.

Prior authorization is required for both the trial insertion and permanent placement for the following non-covered indications:

  1. Dorsal root ganglion stimulator
  2. Peripheral nerve stimulator and peripheral nerve field stimulator
  3. Occipital nerve stimulator

Prior authorization is not required for removal of a spinal cord stimulator.

Coverage

Spinal cord stimulation to treat intractable chronic neuropathic pain that is refractory to other treatment modalities is generally covered as described below, and per your plan documents.

The patient is to be offered patient decision support. The following are recommendations for a robust informed consent discussion between physician and patient:

  1. Provide information about treatment options and their probabilities for success in sufficient detail for decision making.
  2. Present probabilities of outcomes in an unbiased and understandable way.
  3. Include methods for clarifying and expressing patients’ values.

Indications that are covered

Spinal cord stimulation is covered to treat intractable chronic neuropathic pain that is:

  1. Refractory to other treatment modalities (see “Criteria for a trial insertion ” item #1); and
  2. The result of one of the following:
    1. Failed back surgery syndrome with intractable radicular pain refractory to medical management. Note: Medical management for this condition must include Physical Therapy (PT). In addition, an Oswestry disability index (ODI) is required; or
    2. Complex regional pain syndrome, including upper or lower extremity pain. or
    3. Diabetic peripheral neuropathy
Criteria for a trial insertion

Documentation submitted by the operating physician demonstrating compliance with all of the following criteria:

  1. The treatment is recommended after all other patient-appropriate therapies have been tried and proven ineffective, including but not limited to pharmacological management, injection therapies, physical therapy, surgery and psychological treatment if indicated. Documentation for failed back surgery syndrome must include Oswestry Disability Index (ODI) scores from the first and last therapy visits prior to implantation of SCS that demonstrate less than 30% improvement.
  2. Preoperative psychiatric/psychological evaluation conducted by a licensed psychiatrist, psychologist or other licensed mental health professional who has a working knowledge of the psychological issues involved in chronic pain syndromes. The goals of this assessment are to rule out major psychiatric comorbidities or major substance abuse issues that would be strong predictors of poor outcomes and to select motivated patients who would be more likely to adhere to a follow-up plan.
  3. Documentation of severe pain and disability.
    1. For low back pain, the most recent pre-trial ODI is equal to or greater than 40% disability.
    2. For complex regional pain syndrome an ODI is not required.

Conservative therapy must include physical therapy (PT) and may include activity modification, weight loss, and drug therapy. Documentation must correspond to the current episode of pain (within 6 months).

Formal physical therapy, at least four visits over a six week course, including active muscle conditioning is required, or there must be an explicit statement in the clinical documents that explains why such physical therapy (PT) is contraindicated. The requirement for PT will not be met if there is a failure to complete prescribed PT for non-clinical reasons. Documentation of formal PT would be the therapist’s notes. If a patient is unable to complete PT due to progressively, worsening pain and disability, the case will be reviewed on an individual basis by an internal physician reviewer. Documentation in the physical therapist’s notes demonstrating this must be submitted.

Criteria for Permanent Placement
  1. All of the criteria listed above and
  2. A trial insertion of a minimum of three days (preceding permanent implantation) leads to ≥ 50% pain relief and improvement in function.
Replacement of spinal cord stimulator

The replacement of an existing spinal cord stimulator is considered medically necessary for an individual when the existing stimulator and or battery/generator is no longer under warranty and cannot be repaired

Indications that are not covered

  1. Use of spinal cord stimulation (SCS) is considered experimental and investigational for the following conditions, including but not limited to:
    1. Chronic pain from malignancy (cancer);
    2. Other chronic non-malignant pain, including but not limited to, cephalgia, headache, inguinal pain, intercostal neuralgia, occipital neuralgia, phantom limb syndrome, post-herpetic neuralgia, and trigeminal neuralgia;
    3. Spasticity disorders.
    4. For cervical SCS: cervical trauma, disc herniation, or failed cervical spine surgery syndrome, presenting with arm pain, neck pain, or cervicogenic headache;
    5. Any conditions not listed as covered.
  2. Dorsal root ganglion (DRG) stimulation is considered experimental and investigational because it’s efficacy and safety have not been established
  3. Peripheral nerve stimulation (PNS) including peripheral nerve field stimulation (PNFS) (64999) is considered experimental and investigational because its efficacy and safety have not been established.
  4. Occipital nerve stimulation is considered experimental and investigational because its efficacy and safety have not been established

Definitions

Dorsal root ganglion (DRG) stimulation is a modified SCS technique that specifically targets the spinal cord’s afferent sensory neurons

Occipital nerve stimulation (ONS) also called peripheral nerve stimulation (PNS) of the occipital nerves, is used to treat intractable chronic migraine patients. The treatment involves the use of mild electrical impulses to stimulate the greater occipital nerve and lesser occipital nerve which are part of the peripheral nervous system and are located at the back of the head just above the neck area.

Peripheral nerve (PNS) and peripheral field stimulation (PNFS) is a type of neuromodulation, which is a surgical procedure that implants electrodes in the body to change how the nervous system works. Peripheral nerve and field stimulation involves placing the electrodes directly on nerves or under the skin in the region of pain. It is a minimally invasive procedure, requiring a small incision over the targeted area. Peripheral nerve and field stimulation is different from spinal cord stimulation because it places the stimulating device directly over the nerve at the targeted pain area, not on the spinal cord where the nerve originates

Spinal Cord Stimulation (SCS) also known as a dorsal column stimulator involves electrical stimulation of spinal nerves using electrodes implanted in the epidural space of the spinal column. The goal of SCS is to suppress pain in specific areas for patients with a variety of chronic pain disorders, including chronic, refractory, neuropathic pain.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

63650

Percutaneous implantation of neurostimulator electrode array, epidural

63655

Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural

63661

Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed

63662

Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed

63663

Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed

63664

Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed

63685

Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling

63688

Revision or removal of implanted spinal neurostimulator pulse generator or receiver

64555

Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)

64575

Incision for implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)

64585

Revision or removal of peripheral neurostimulator electrode array

64590

Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling

64595

Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver

64999

Unlisted procedure, nervous system

95970

Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (ie, cranial nerve, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming

95971

Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming

95972

Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour

95973

Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)

L8679

Implantable neurostimulator, pulse generator, any type

L8680

Implantable neurostimulator electrode, each

L8681

Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only

L8682

Implantable neurostimulator radiofrequency receiver

L8683

Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver

L8685

Implantable neurostimulator pulse generator, single array, rechargeable, includes extension

L8686

Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension

L8687

Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension

L8688

Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension

L8689

External recharging system for battery (internal) for use with implantable neurostimulator, replacement only

C1767

Generator, neurostimulator (implantable), nonrechargeable

C1778

Lead, neurostimulator (implantable)

C1787

Patient programmer, neurostimulator

C1816

Receiver and/or transmitter, neurostimulator (implantable)

C1820

Generator, neurostimulator (implantable), with rechargeable battery and charging system

C1822

Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system

C1883

Adaptor/extension, pacing lead or neurostimulator lead (implantable)

C1897

Lead, neurostimulator test kit (implantable)

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

References

  1. Abdi, S, Complex regional pain syndrome in adults: Prevention and management In: UpToDate, Rosenquist, E (Ed), UpToDate, Waltham, MA. (Accessed on December, 14,2015 and December 7, 2017)
  2. Deer T, Pope J, Benyamin R, et al. Prospective, multicenter, randomized, double-blinded, partial crossover study to assess the safety and efficacy of the novel neuromodulation system in the treatment of patients with chronic pain of peripheral nerve origin. Neuromodulation. 2016;19:91-100
  3. ECRI Institute. (2013). Response Implantable Peripheral Nerve Stimulation Devices for Treating Chronic Pain. Plymouth Meeting, PA: ECRI Institute.
  4. ECRI, Institute (2014). Rechargeable Implantable Neurostimulators (Spinal Cord Stimulators) for Managing Chronic Pain. ECRI Institute. Plymouth Meeting, PA.
  5. ECRI Institute. (2017). Dorsal Root Ganglion Neurostimulation for Treating Complex Regional Pain Syndrome Types I and II. Plymouth Meeting, PA: ECRI Institute.
  6. Garza I, Schwedt TJ. Chronic Migraine. In: UpToDate, Dashe JF (Ed), UpToDate, Waltham, MA. Accessed November 21, 2017.
  7. Hayes, Inc. Hayes search & summary. Peripheral Nerve Field Stimulation for the Treatment of Chronic Abdominal Pain. Lansdale, PA: Hayes, Inc.; April, 2017
  8. Hayes, Inc. Hayes Medical Technology Directory Report. Occipital Nerve Stimulation for Chronic Cluster Headache and Chronic Migraine Headache. Lansdale, PA: Hayes, Inc.; published May 2012; reviewed May 2014; May 2015
  9. Hayes, Inc. Hayes search & summary. Peripheral Nerve Stimulation for Low Back Pain. Lansdale, PA: Hayes, Inc.; June, 2015.
  10. Hayes, Inc. Hayes Medical Technology Directory Report. Spinal Cord Stimulation for relief of neuropathic pain. Lansdale, PA: Hayes, Inc.; August, 2013, Reviewed October 2015.
  11. Hayes, Inc. Hayes Health Technology Brief. Dorsal Root Ganglion Stimulation for the Treatment of Complex Regional Pain Syndrome. Lansdale, PA: Hayes, Inc.; December , 2017
  12. Hayes, Inc. Hayes Health Technology Brief. Electrical Stimulation of the Occipital Nerve for Treatment of Occipital Neuralgia. Lansdale, PA: Hayes, Inc.; published December 2011; reviewed January 2014; archived January 29, 2015
  13. Hong, J., Ball, P. A., & Fanciullo, G. J. (2014). Neurostimulation for Neck Pain and Headache. Headache: The Journal of Head and Face Pain, 54(3), 430-444. doi:10.1111/head.12292
  14. Peng, Lihua, et al. “Spinal cord stimulation for cancer-Related pain in adults.” Cochrane Database of Systematic Reviews, 2015, doi:10.1002/14651858.cd009389.pub3.
  15. Matharu,M. Short-lasting unilateral neuralgiform headache attacks: Treatment. In: UpToDate, Swanson, J (MD), UpToDate, Waltham, MA. (March 19, 2018.
  16. Mckenzie-Brown, A. Spinal cord stimulation: Placement and management. In: UpToDate, Fishman, S, (Ed), UpToDate, Waltham, MA. (Accessed on December 7, 2017.)National Institute for Health and Care Excellence (NICE). Peripheral nerve-field stimulation for chronic low back pain: guidance [IPG451]. 2013; https://www.nice.org.uk/guidance/ipg451 Accessed January 4, 2018.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 02/28/2011 - Date of origin
  • 04/05/2018 - Effective date
Review date
  • 01/2018
Revision date
  • 04/05/2018

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