Criteria
Spinal cord stimulation with standard or high-frequency stimulation may be considered medically necessary for treatment of severe and chronic pain of the trunk or limbs that is refractory to all other pain therapies when performed according to policy guidelines.
Dorsal root ganglion neurostimulation is considered medically necessary for the treatment of severe and chronic pain of the trunk or limbs that is refractory to all other pain therapies when performed according to policy guidelines.
Spinal cord stimulation is considered investigational in all other situations including, but not limited to, treatment of critical limb ischemia to forestall amputation and treatment of refractory angina pectoris, heart failure, and cancer-related pain.
Policy Guidelines
Individual selection focuses on determining whether the individual is refractory to other types of treatment. The following considerations may apply.
- The treatment is used only as a last resort; other treatment modalities (pharmacologic, surgical, psychological, physical, if applicable) have failed or are judged to be unsuitable or contraindicated;
- Pain is neuropathic in nature (ie, resulting from actual damage to the peripheral nerves). Common indications include, but are not limited to, failed back surgery syndrome, complex regional pain syndrome (i.e., reflex sympathetic dystrophy), arachnoiditis, radiculopathies, phantom limb/stump pain, and peripheral neuropathy. Spinal cord stimulation is generally not effective in treating nociceptive pain (resulting from irritation, not damage to the nerves) and central deafferentation pain (related to central nervous system damage from a stroke or spinal cord injury).
- No serious untreated drug habituation exists;
- Demonstration of at least 50% pain relief with a temporarily implanted electrode precedes permanent implantation;
- All the facilities, equipment, and professional and support personnel required for the proper diagnosis, treatment, and follow-up of the individual are available.
"Burst" neurostimulation is an alternate programming of a standard SCS device. A clinician programmer application is used to configure a standard SCS device to provide stimulation in "bursts" rather than at a constant ("tonic") rate.
The Centers for Medicare & Medicaid Services has issued instructions that the existing implantable neurostimulator code C1820 should only be used for stimulators that are not high frequency.
Removal Guidelines
One time removal or revision of stimulator will be allowed per medical necessity criteria, (i.e., current stimulator is out of warranty).
Repeat removal or revision requests of stimulator will be reviewed by the Medical Director.
Removal of stimulator for technology upgrade when stimulator is still under warranty is not covered.
Procedure Codes
| 63650 |
63655 |
63661 |
63662 |
63663 |
63664 |
63685 |
| 63688 |
95970 |
95971 |
95972 |
C1767 |
C1778 |
C1787 |
| C1820 |
C1822 |
C1883 |
C1897 |
L8679 |
L8680 |
L8685 |
| L8686 |
L8687 |
L8688 |
