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Spinal Cord and Dorsal Root Ganglion Stimulation

Section: Surgery
Effective Date: March 01, 2019
Revised Date: June 14, 2019
Last Reviewed: March 16, 2020

Description

Spinal cord stimulation (SCS) delivers low-voltage electrical stimulation to the dorsal columns of the spinal cord to block the sensation of pain; this is achieved through a surgically implanted SCS device, which comes equipped with a radio frequency receiver. The neurostimulator device is also issued with a standard power source (battery) that can be implanted or worn externally. Other neurostimulators target the dorsal root ganglion.

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.

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

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 Annual Review-no changes

Links

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.