Notification

Spinal Cord and Dorsal Root Ganglion Stimulation


Notification Issue Date: 10/16/2018

This version of the policy will become effective on 01/14/2019.

Dorsal root ganglion (DRG) stimulation continues to be considered experimental/investigational by the Company and not covered. Pro­claim DRG neurostimulator (previously known as Axium Neurostimulator System) was added as an example of DRG stimulation system that is considered experimental/investigational by the Company and not covered.


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Note: On 01/10/2019 the following revisions were made to the Coding Table as part of the 01/01/2019 CPT/HCPCS coding update:

  • The following code was added: C1823
  • The narratives of the following procedure codes were revised: 95970, 95971, 95972



Medicare Advantage Policy

Title:Spinal Cord and Dorsal Root Ganglion Stimulation
Policy #:MA11.031g

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

IMPLANTATION OF A TEMPORARY SPINAL CORD STIMULATION (SCS) DEVICE

A trial period utilizing a temporary SCS device is considered medically necessary and, therefore, covered for the relief of chronic intractable pain when all of the following criteria are met:
  • The individual has undergone careful screening, including evaluation by a multi-disciplinary team that confirms the existence of one of the following conditions:
    • Lumbosacral arachnoiditis (arachnoiditis is usually documented by the presence of high levels of proteins in the cerebrospinal fluid and/or by myelography or magnetic resonance imaging).
    • Nerve root injuries that are post-surgical or post-traumatic, including post-laminectomy syndrome (failed back syndrome) and cauda equina injury
    • Complex regional pain syndrome (CRPS), type I or type II (formerly known as reflex sympathetic dystrophy syndrome/causalgia)
  • Type I CRPS is associated with symptomatic tissue injury.
  • Type II CRPS is associated with nerve injury.
    • Incomplete spinal cord injury
    • Intercostal neuralgia
    • Phantom limb syndrome
    • Peripheral neuropathy
    • Post-herpetic neuralgia
    • Radiculopathy
    • End-stage peripheral vascular disease, when an individual cannot undergo revascularization or when revascularization has failed to relieve painful symptoms
    • Plexopathy
  • The individual does not have any untreated, existing drug dependence.
  • The implantation of the stimulator is used only after the provision of other evidence-based treatment modalities (pharmacological, surgical, physical, or psychological) have been tried for at least six consecutive months and did not prove satisfactory or are judged to be unsuitable or contraindicated for an individual.

IMPLANTATION OF A PERMANENT SPINAL CORD STIMULATION (SCS) DEVICE

The implantation of a permanent SCS device for standard or high frequency spinal cord stimulation is considered medically necessary and, therefore, covered for the relief of chronic intractable pain of the trunk or limbs when the medical record documents both of the following:
  • The individual reports a reduction in pain of 50 percent or more since the start of the trial period of a temporary SCS device.
  • There is objective evidence of pain relief (e.g., decreased opioid usage, improved range of motion of the affected area, increased activity, increased pain relief according to the Visual Analog Scale [VAS] or the Numeric Pain Intensity Scale).

REMOVAL/REVISION OF A SPINAL CORD STIMULATION (SCS) DEVICE

The removal/revision of an SCS device, or services and supplies related to such removal/revision, are considered medically necessary and, therefore, covered for any of the following indications:
  • Migration of a lead
  • Loss of effectiveness
  • Intolerance by an individual
  • Infection
  • Painful generator site
  • Need for an automatic implantable cardioverter defibrillator (AICD)
  • Development of neurologic deficits
  • Need for a magnetic resonance imaging (MRI) study

NOT MEDICALLY NECESSARY

REMOVAL/REPLACEMENT OF A STANDARD SPINAL CORD STIMULATION (SCS) DEVICE
Requests for technological advancements or newly released upgrades to a standard SCS device when the original SCS device still functions properly and/or there are no significant changes in the individual's condition are considered not medically necessary and are not covered.

EXPERIMENTAL/INVESTIGATIONAL

SPINAL CORD STIMULATION
Use of an SCS device for all other conditions, including refractory angina pectoris, pain associated with malignancy (except peripheral neuropathy associated with malignancy), and heart failure, is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

DORSAL ROOT GANGLION (DRG)
Although the US Food and Drug Administration (FDA) has approved devices for dorsal root ganglion (DRG) stimulation, (e.g., Pro­claim DRG neurostimulator (previously known as Axium Neurostimulator System), the Company has determined that the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature. Therefore, DRG stimulation is considered experimental/investigational by the Company and not covered.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the professional provider's office, hospital, nursing home, home health agencies, therapies and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

REIMBURSEMENT FOR ELECTRODE DEVICE COMPONENT IN CONJUNCTION WITH LEAD IMPLANTATION PROCEDURE

Providers must not report electrode device component, HCPCS code L8680, in conjunction with lead implantation procedure CPT code 63650 in any setting. HCPCS code L8680 is considered incidental to CPT code 63650 and is not eligible for separate reimbursement by the Company.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination for spinal cord stimulation (SCS). The Company’s payment methodology may differ from Medicare.

A trial period for the placement of a temporary external SCS device is needed to determine if permanent implantation will be successful; if stimulation is the appropriate modality for the type, location, and severity of pain; and to evaluate the effectiveness of various stimulation settings of the device.
  • The trial period using the temporary external SCS device is typically three to five days but may be extended up to four weeks if necessary

The safety and effectiveness of SCS have not been established for pediatric use (individuals under the age of 18 years), for an unborn fetus, or for individuals during pregnancy and delivery.

CONTRAINDICATIONS FOR SPINAL CORD STIMULATION
  • Medical conditions that require exposure to diathermy (deep heat treatment including short-wave diathermy, microwave diathermy, and ultrasound diathermy)
  • Inability to properly operate the stimulator

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, SCS is covered under the medical benefits of the Company's Medicare Advantage products when the medical necessity criteria listed in this medical policy are met. However, services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous devices approved by the FDA for SCS and DRG.

BILLING GUIDELINES

The Current Procedural Terminology codes listed in this policy should not be used to report treatment of individuals with acupuncture, nor should they be used for any variation of the acupuncture techniques.

Generally, electronic analysis services should only be reported once every 30 days.

Description

SPINAL CORD STIMULATION (SCS)

Spinal cord stimulation (SCS), which is also known as dorsal column stimulation (DCS), is a nondestructive, reversible procedure that provides low-voltage electrical stimulation to block sensations of pain in the dorsal column of the spinal cord. SCS is used to treat certain types of chronic pain. Although the stimulation blocks pain conduction pathways to the brain and may stimulate endorphins, it does not eliminate the source of pain. SCS is most commonly used to control chronic intractable pain (from conditions such as failed back syndrome or nerve root injuries). It has been proposed that SCS and the stimulation of selected nerve fibers have the potential to augment blood flow, decrease catecholamines, and reduce inflammation, so that SCS may further benefit individuals with conditions such as heart failure.

The SCS device consists of a neurostimulator that transmits electrical impulses to the spinal cord through an implanted lead/wire. SCS should be used as a late (if not last) resort when other conservative treatment modalities (pharmacological, surgical, physical, or psychological) have proven unsatisfactory, unsuitable, or when they have been contraindicated for an individual.

Standard SCS devices use electrical stimulation with a frequency on the order of 100 to 1000 Hz while high-frequency devices use a higher frequency of 10,000 Hz. Burst-stimulation devices work in conjunction with standard SCS devices through an approved application where stimulation is provided in five 500 Hz burst spikes at a rate of 40 Hz, with a pulse width of 1 ms. High frequency and burst stimulation are proposed to be associated with fewer paresthesias, which are recognized effects of SCS.

Prior to the surgical implantation of a permanent SCS device, an individual is provided with a temporary external neurostimulator for a trial period of three to five days. The neurostimulator electrodes used for this purpose are implanted percutaneously in the epidural space through a special needle, although some individuals may need an open procedure requiring laminectomy to place the electrodes. During the procedure, which is performed in the outpatient setting under conscious sedation or monitored anesthesia care, the lead is attached to an external generator/power supply that is worn on a belt, and stimulation settings are programmed.

During the trial period, the neurostimulator is left in place, and the individual keeps a written log of the stimulation settings during different activities, along with the level of pain relief. If the trial is successful (i.e., the medical record documents a reduction in pain of 50 percent or more since the start of the trial period), a permanent spinal neurostimulator and pulse generator (which is activated through a radiofrequency device) are implanted subcutaneously. This may be done by connecting the pulse generator to the electrodes that are already implanted. Alternatively, the trial electrodes are often removed after the trial, and implantation of new electrodes and the pulse generator are performed as a separate procedure. The electrode placement for implantation may be performed via laminotomy or percutaneous approach. Documentation of the reduction in pain should be based on objective evidence of pain relief (e.g., decreased opioid usage, improved range of motion of the affected area, increased activity, increased pain relief according to the Visual Analog Scale [VAS] or the Numeric Pain Intensity Scale).

On rare occasions, surgical revisions may be needed if the neurostimulator electrodes migrate or move from the area needing stimulation. Also, if an individual is unable to tolerate the electrodes, the individual has an onset of neurologic deficits, the modality itself becomes ineffective over time, or if the leads and/or pulse generator become infected, the device may be removed. In addition, if an individual develops certain medical conditions (e.g., severely impaired left-ventricular function) that cause a need for an automatic implantable cardioverter defibrillator (AICD), this may necessitate the removal of the SCS device because the SCS signals may be falsely interpreted by the AICD.

Reviews of current published peer-reviewed literature have found support for the use of the SCS device to treat refractory trunk or limb pain in individuals who have failed all other conservative evidence-based treatment modalities. For other potential indications, such as refractory angina pectoris, malignancy-related pain (except peripheral neuropathy associated with malignancy), and heart failure, there is insufficient evidence from controlled trials with no long-term follow-up data to conclude that SCS improves the net health outcome.

Competency to perform services related to SCS can be demonstrated through the completion of specialized training. Several organizations offer credentialing for clinical services related to SCS (e.g., the American Board of Neurophysiological Monitoring [ABNM], the American Board of Clinical Neurophysiology [ABCN], and the American Society of Electroneurodiagnostic Technologists, Inc. [ASET]).

A number of implantable spinal cord stimulation devices have received US Food and Drug Administration (FDA) premarket approval (PMA) indicated as an aid in the management of chronic intractable pain of the trunk and/or limbs, including unilateral or bilateral pain associated with failed back surgery syndrome, and intractable low back pain and leg pain.

DORSAL ROOT GANGLION STIMULATION

Another variation of SCS is dorsal root ganglion (DRG) stimulation where the tip of the neurostimulator lead is placed near the target DRG. The DRG is a bundle of sensory nerve cell bodies that are located between the spinal nerves and the spinal cord on the posterior root and are believed to play an important role in neuropathic pain perception.

In February 2016, the Axium Neurostimulator System (Spinal Modulation), [now known as as Pro­claim DRG neurostimulator], was approved by FDA through the premarket approval process. This implanted device stimulates the dorsal root ganglion. Further, it is indicated as an aid in the management of moderate-to-severe intractable pain of the lower limbs in adults with complex regional pain syndrome types I and II.

In August 2016, the Freedom Spinal Cord Stimulator (Stimwave Technologies), a wireless injectable stimulator, was cleared for marketing by FDA through the 510(k) process for treating chronic, intractable pain of the trunk and/or lower limbs. The Freedom device has implantable or injectable microstimulators that contain electrode(s). The microstimulators with electrodes are powered by a wireless battery pack worn externally. The device can be placed to target the spinal cord (i.e., levels T7 to L5) or to target the dorsal root ganglion.

Chang Chien et al. (2017) published a systematic review on intraspinal stimulation of nondorsal column targets, including neurostimulation of the DRG for chronic pain. Reviewers included reports published through March 2015. They identified 6 studies of DRG stimulation: 1 conference presentation of the preliminary RCT data from the ACCURATE trial (discussed below), 4 publications describing 3 prospective observational studies, and 1 retrospective chart review. In the 3 prospective observational studies (N=32, 10, and 8), follow-up ranged from 7 days to 12 months. The retrospective study reported on 25 patients with a follow-up to 32 weeks.

One unblinded randomized controlled trial(s) (RCT(s)), which was for Axium Neurostimulator System (now known as Pro­claim DRG neurostimulator), and several case series have evaluated DRG neurostimulators in individuals with chronic trunk and/or limb pain. The RCT (N=152) found that patients receiving DRG neurostimulation had significantly higher rates of treatment success at 3 and 12 months than those receiving standard SCS devices. Both groups experienced paresthesias but patients in the DRG group reported less postural variation in paresthesia and reduced extraneous stimulation in nonpainful areas. Patients in the DRG group also reported more improvement in interference with physical functioning and mood states. Rates of serious adverse events were similar. Several case series have also been published. The largest series, which had the longest follow-up, found that 60% of patients had 50% or greater reduction in overall pain at 12 months. While outcomes have been favorable, additional RCTs are needed to provide greater certainty in the treatment benefit.
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US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Freedom Spinal Cord Stimulator (SCS) System. 510(k) summary. [FDA Web site]. 10/10/2014. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf14/k141399.pdf. Accessed July 14, 2017.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Implanted Spinal Cord Stimulator for Pain Relief: Medtronic Models 3890, 3891, and 3892 Leads. 510(k) summary. [FDA Web site]. 10/30/03. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf3/k033016.pdf. Accessed June 9, 2017.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. New device approval. Genesis Neuromodulation (IPG) System. [FDA Web site]. 11/21/01. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf/P010032a.pdf. Accessed June 9, 2017.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. New device approval. PRECISION™ Spinal Cord Stimulator (SCS) System. [FDA Web site]. 04/27/04. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf3/p030017a.pdf. Accessed June 9, 2017.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Nevro Senza Spinal Cord Stimulation (SCS) System. Premarket Approval (PMA) Database. [FDA Web site]. 05/08/2015. Available at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P130022. Accessed June 9, 2017.

US Food and Drug Administration (FDA). Summary of Safety and Effectiveness Data (SSED): Senza Spinal Cord Stimulation (SCS) System 2015; Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf13/P130022b.pdf. Accessed June 9, 2017.

Verrills P, Sinclair C, Barnard A. A review of spinal cord stimulation systems for chronic pain. J Pain Res. 2016;9:481-492.

Zipes DP, Neuzil P, Theres H, et al. Determining the feasibility of spinal cord neuromodulation for the treatment of chronic systolic heart failure: the DEFEAT-HF study. JACC Heart Fail.2015; pii: S2213-1779(15)00684-8. [Epub ahead of print].

Zipes DP, Svorkdal N, Berman D, et al. Spinal cord stimulation therapy for patients with refractory angina who are not candidates for revascularization. Neuromodulation. 2012;15(6):550-559.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, 95970, 95971, 95972


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Report the most appropriate diagnosis code in support of medical necessity as listed in the policy.


HCPCS Level II Code Number(s)



C1767 Generator, neurostimulator (implantable), nonrechargeable

C1778 Lead, neurostimulator (implantable)

C1787 Patient programmer, neurostimulator

C1816 Receiver and/or transmitter, neurostimulator (implantable)

C1883 Adaptor/extension, pacing lead or neurostimulator lead (implantable)

C1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system

C1822 Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system

C1823 Generator, neurostimulator (implantable), non-rechargeable, with transvenous sensing and stimulation leads

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, singe 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

L8695 External recharging system for battery (external) for use with implantable neurostimulator, replacement only



Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

Revisions from MA11.031g:
01/14/2019This version of the policy will become effective on 01/14/2019.

Dorsal root ganglion (DRG) stimulation continues to be considered experimental/investigational by the Company and not covered. Pro­claim DRG neurostimulator (previously known as Axium Neurostimulator System) was added as an example of DRG stimulation system that is considered experimental/investigational by the Company and not covered.

_________________________________________________________

On 01/10/2019 the following revisions were made to the Coding Table as part of the 01/01/2019 CPT/HCPCS coding update:
  • The following code was added: C1823
  • The narratives of the following procedure codes were revised: 95970, 95971, 95972


Revisions from MA11.031f:
03/01/2018This version of the policy will become effective on 03/01/2018.

The policy has been reviewed to communicate the Company’s continuing position on Spinal Cord and Dorsal Root Ganglion Stimulation.

An attachment to this policy with the list of ICD-10 codes was removed.


Revisions from MA11.031e:
11/21/2017This version of the policy will become effective 11/21/2017.

Name change:
From: Spinal Cord Stimulation (Dorsal Column Stimulation)
To: Spinal Cord and Dorsal Root Ganglion Stimulation

The following criteria have been added to this policy:
  • cauda equina injury
  • incomplete spinal cord injury
  • intercostal neuralgia
  • post herpetic neuralgia

This policy was expanded to communicate Company's position of experimental/investigational for wireless injectable dorsal root ganglion neurostimulation for the treatment of severe and chronic pain of the trunk or limbs.

The policy was updated to clarify the coverage of the removal/replacement of a functioning standard SCS.

New peer-reviewed literature was added on the use of high frequency stimulation and dorsal root ganglion stimulation.


Revisions from MA11.031d:
10/01/2016This version of the policy will become effective 10/01/2016.

The following ICD-10 CM codes have been deleted from this policy:

M50.12 Cervical disc disorder with radiculopathy, mid-cervical region
T85.84XA Pain due to internal prosthetic devices, implants and grafts, not elsewhere classified, initial encounter
T85.84XD Pain due to internal prosthetic devices, implants and grafts, not elsewhere classified, subsequent encounter
T85.84XS Pain due to internal prosthetic devices, implants and grafts, not elsewhere classified, sequela
T85.89XA Other specified complication of internal prosthetic devices, implants and grafts, not elsewhere classified, initial encounter
T85.89XD Other specified complication of internal prosthetic devices, implants and grafts, not elsewhere classified, subsequent encounter
T85.89XS Other specified complication of internal prosthetic devices, implants and grafts, not elsewhere classified, sequela

The following ICD-10 CM codes have been added to this policy:

M50.120, M50.121, M50.122, M50.123, T85.193A, T85.193D, T85.193S, T85.733A, T85.733D, T85.733S, T85.734A, T85.734D, T85.734S, T85.840A, T85.840D, T85.840S, T85.890A, T85.890D, T85.890S


The following ICD-10 CM narratives have been revised in this policy:

T85.112A
FROM: Breakdown (mechanical) of implanted electronic neurostimulator (electrode) of spinal cord, initial encounter
TO: Breakdown (mechanical) of implanted electronic neurostimulator of spinal cord electrode (lead), initial encounter

T85.112D
FROM: Breakdown (mechanical) of implanted electronic neurostimulator (electrode) of spinal cord, subsequent encounter
TO: Breakdown (mechanical) of implanted electronic neurostimulator of spinal cord electrode (lead), subsequent encounter

T85.112S
FROM: Breakdown (mechanical) of implanted electronic neurostimulator (electrode) of spinal cord, sequela
TO: Breakdown (mechanical) of implanted electronic neurostimulator of spinal cord electrode (lead), sequela

T85.122A
FROM: Displacement of implanted electronic neurostimulator (electrode) of spinal cord, initial encounter
TO: Displacement of implanted electronic neurostimulator of spinal cord electrode (lead), initial encounter

T85.122D
FROM: Displacement of implanted electronic neurostimulator (electrode) of spinal cord, subsequent encounter
TO: Displacement of implanted electronic neurostimulator of spinal cord electrode (lead), subsequent encounter

T85.122S
FROM: Displacement of implanted electronic neurostimulator (electrode) of spinal cord, sequela
TO: Displacement of implanted electronic neurostimulator of spinal cord electrode (lead), sequela

T85.192A
FROM: Other mechanical complication of implanted electronic neurostimulator (electrode) of spinal cord, initial encounter
TO: Other mechanical complication of implanted electronic neurostimulator of spinal cord electrode (lead), initial encounter

T85.192D
FROM: Other mechanical complication of implanted electronic neurostimulator (electrode) of spinal cord, subsequent encounter
TO: Other mechanical complication of implanted electronic neurostimulator of spinal cord electrode (lead), subsequent encounter

T85.192S
FROM: Other mechanical complication of implanted electronic neurostimulator (electrode) of spinal cord, sequela
TO: Other mechanical complication of implanted electronic neurostimulator of spinal cord electrode (lead), sequela


Revisions from MA11.031c:
02/03/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on Spinal Cord Stimulation (Dorsal Column Stimulation).
01/01/2016The following CPT code has been deleted from this policy: 95973
The following CPT narrative has been revised in this policy: 95972


Revisions from MA11.031b
10/01/2015The following ICD-10 CM narrative has been revised in this policy: M50.11


Revisions from MA11.031a:
04/22/2015This policy was updated to communicate the following:
  • Company's position of experimental/investigational for spinal cord stimulation for heart failure
  • Contraindicated uses for spinal cord stimulation

The following ICD-10 CM codes have been removed from this policy:

G89.3, I20.1,I20.8, I20.8, I20.9 I25.111, I25.118, I25.119, I25.701, I25.708, I25.709, I25.711, I25.718, I25.719, I25.721, I25.728, I25.729, I25.731, I25.738, I25.739, I25.751, I25.758, I25.759, I25.761, I25.768, I25.769, I25.791, I25.798, I25.799.

The following ICD-9 CM codes have been removed from this policy:

338.3 Neoplasm related pain (acute) (chronic)
413.0 Angina decubitus
413.1 Prinzmetal angina
413.9 Other and unspecified angina pectoris


Revisions from MA11.031:
01/01/2015This is a new policy. This policy has been identified for the CPT code update, effective 01/01/2015.

The following CPT narrative has been revised in the policy:

95972

FROM: 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); COMPLEX SPINAL CORD, OR PERIPHERAL (IE, PERIPHERAL NERVE, AUTONOMIC NERVE, SACRAL NERVE, NEUROMUSCULAR) (EXCEPT CRANIAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER, WITH INTRAOPERATIVE OR SUBSEQUENT PROGRAMMING, FIRST HOUR

TO: 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); complex spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, up to 1 hour




Version Effective Date: 01/14/2019
Version Issued Date: 01/14/2019
Version Reissued Date: N/A