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



Medical Policy Bulletin


Title:Spinal Cord and Dorsal Root Ganglion Stimulation

Policy #:11.15.01u

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

MEDICALLY NECESSARY

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 of the trunk or limbs 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 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

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) STIMULATION
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.

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.

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.
Guidelines

A trial period for the placement of a temporary external spinal cord stimulation (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 has 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 benefit contract, spinal cord stimulation (dorsal column stimulation) is covered under the medical benefits of the Company’s 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. 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)

FOR THE TREATMENT OF CHRONIC INTRACTABLE PAIN, IMPLANTATION OF A SPINAL CORD STIMULATION (SCS) DEVICE IS MEDICALLY NECESSARY WHEN REPORTED WITH ONE OF THE FOLLOWING DIAGNOSIS CODES

G89.21 Chronic pain due to trauma

G89.22 Chronic post-thoracotomy pain

G89.28 Other chronic postprocedural pain

G89.29 Other chronic pain

G89.3 Neoplasm related pain (acute) (chronic)

G89.4 Chronic pain syndrome

THE FOLLOWING DIAGNOSIS CODES REPRESENT POTENTIAL ETIOLOGY OF CHRONIC INTRACTABLE PAIN AS OUTLINED IN THE POLICY CRITERIA

B02.0 Zoster encephalitis

B02.22 Postherpetic trigeminal neuralgia

B02.29 Other postherpetic nervous system involvement

G03.9 Meningitis, unspecified

G54.0 Brachial plexus disorders

G54.1 Lumbosacral plexus disorders

G54.6 Phantom limb syndrome with pain

G54.7 Phantom limb syndrome without pain

G54.8 Other nerve root and plexus disorders

G55 Nerve root and plexus compressions in diseases classified elsewhere

G56.40 Causalgia of unspecified upper limb

G56.41 Causalgia of right upper limb

G56.42 Causalgia of left upper limb

G56.43 Causalgia of bilateral upper limbs

G56.80 Other specified mononeuropathies of unspecified upper limb

G56.81 Other specified mononeuropathies of right upper limb

G56.82 Other specified mononeuropathies of left upper limb

G56.83 Other specified mononeuropathies of bilateral upper limbs

G56.90 Unspecified mononeuropathy of unspecified upper limb

G56.91 Unspecified mononeuropathy of right upper limb

G56.92 Unspecified mononeuropathy of left upper limb

G56.93 Unspecified mononeuropathy of bilateral upper limbs

G57.70 Causalgia of unspecified lower limb

G57.71 Causalgia of right lower limb

G57.72 Causalgia of left lower limb

G57.73 Causalgia of bilateral lower limbs

G57.80 Other specified mononeuropathies of unspecified lower limb

G57.81 Other specified mononeuropathies of right lower limb

G57.82 Other specified mononeuropathies of left lower limb

G57.83 Other specified mononeuropathies of bilateral lower limbs

G57.90 Unspecified mononeuropathy of unspecified lower limb

G57.91 Unspecified mononeuropathy of right lower limb

G57.92 Unspecified mononeuropathy of left lower limb

G57.93 Unspecified mononeuropathy of bilateral lower limbs

G58.0 Intercostal neuropathy

G60.0 Hereditary motor and sensory neuropathy

G60.3 Idiopathic progressive neuropathy

G60.8 Other hereditary and idiopathic neuropathies

G60.9 Hereditary and idiopathic neuropathy, unspecified

G63 Polyneuropathy in diseases classified elsewhere

G90.50 Complex regional pain syndrome I, unspecified

G90.511 Complex regional pain syndrome i of right upper limb

G90.512 Complex regional pain syndrome i of left upper limb

G90.513 Complex regional pain syndrome i of upper limb, bilateral

G90.519 Complex regional pain syndrome i of unspecified upper limb

G90.521 Complex regional pain syndrome i of right lower limb

G90.522 Complex regional pain syndrome i of left lower limb

G90.523 Complex regional pain syndrome i of lower limb, bilateral

G90.529 Complex regional pain syndrome i of unspecified lower limb

G90.59 Complex regional pain syndrome i of other specified site

I70.221 Atherosclerosis of native arteries of extremities with rest pain, right leg

I70.222 Atherosclerosis of native arteries of extremities with rest pain, left leg

I70.223 Atherosclerosis of native arteries of extremities with rest pain, bilateral legs

I70.228 Atherosclerosis of native arteries of extremities with rest pain, other extremity

I70.229 Atherosclerosis of native arteries of extremities with rest pain, unspecified extremity

I73.9 Peripheral vascular disease, unspecified

M34.83 Systemic sclerosis with polyneuropathy

M50.10 Cervical disc disorder with radiculopathy, unspecified cervical region

M50.11 Cervical disc disorder with radiculopathy, high cervical region

M50.121 Cervical disc disorder at c4-c5 level with radiculopathy

M50.122 Cervical disc disorder at c5-c6 level with radiculopathy

M50.123 Cervical disc disorder at c6-c7 level with radiculopathy

M50.13 Cervical disc disorder with radiculopathy, cervicothoracic region

M51.14 Intervertebral disc disorders with radiculopathy, thoracic region

M51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar region

M51.16 Intervertebral disc disorders with radiculopathy, lumbar region

M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region

M54.10 Radiculopathy, site unspecified

M54.11 Radiculopathy, occipito-atlanto-axial region

M54.12 Radiculopathy, cervical region

M54.13 Radiculopathy, cervicothoracic region

M54.14 Radiculopathy, thoracic region

M54.15 Radiculopathy, thoracolumbar region

M54.16 Radiculopathy, lumbar region

M54.17 Radiculopathy, lumbosacral region

M54.18 Radiculopathy, sacral and sacrococcygeal region

M54.30 Sciatica, unspecified side

M54.31 Sciatica, right side

M54.32 Sciatica, left side

M54.40 Lumbago with sciatica, unspecified side

M54.41 Lumbago with sciatica, right side

M54.42 Lumbago with sciatica, left side

M79.2 Neuralgia and neuritis, unspecified

M96.1 Postlaminectomy syndrome, not elsewhere classified

S14.0XXA Concussion and edema of cervical spinal cord, initial encounter

S14.0XXD Concussion and edema of cervical spinal cord, subsequent encounter

S14.0XXS Concussion and edema of cervical spinal cord, sequela

S14.101A Unspecified injury at c1 level of cervical spinal cord, initial encounter

S14.101D Unspecified injury at c1 level of cervical spinal cord, subsequent encounter

S14.101S Unspecified injury at c1 level of cervical spinal cord, sequela

S14.102A Unspecified injury at c2 level of cervical spinal cord, initial encounter

S14.102D Unspecified injury at c2 level of cervical spinal cord, subsequent encounter

S14.102S Unspecified injury at c2 level of cervical spinal cord, sequela

S14.103A Unspecified injury at c3 level of cervical spinal cord, initial encounter

S14.103D Unspecified injury at c3 level of cervical spinal cord, subsequent encounter

S14.103S Unspecified injury at c3 level of cervical spinal cord, sequela

S14.104A Unspecified injury at c4 level of cervical spinal cord, initial encounter

S14.104D Unspecified injury at c4 level of cervical spinal cord, subsequent encounter

S14.104S Unspecified injury at c4 level of cervical spinal cord, sequela

S14.105A Unspecified injury at c5 level of cervical spinal cord, initial encounter

S14.105D Unspecified injury at c5 level of cervical spinal cord, subsequent encounter

S14.105S Unspecified injury at c5 level of cervical spinal cord, sequela

S14.106A Unspecified injury at c6 level of cervical spinal cord, initial encounter

S14.106D Unspecified injury at c6 level of cervical spinal cord, subsequent encounter

S14.106S Unspecified injury at c6 level of cervical spinal cord, sequela

S14.107A Unspecified injury at c7 level of cervical spinal cord, initial encounter

S14.107D Unspecified injury at c7 level of cervical spinal cord, subsequent encounter

S14.107S Unspecified injury at c7 level of cervical spinal cord, sequela

S14.108A Unspecified injury at c8 level of cervical spinal cord, initial encounter

S14.108D Unspecified injury at c8 level of cervical spinal cord, subsequent encounter

S14.108S Unspecified injury at c8 level of cervical spinal cord, sequela

S14.109A Unspecified injury at unspecified level of cervical spinal cord, initial encounter

S14.109D Unspecified injury at unspecified level of cervical spinal cord, subsequent encounter

S14.109S Unspecified injury at unspecified level of cervical spinal cord, sequela

S14.111A Complete lesion at c1 level of cervical spinal cord, initial encounter

S14.111D Complete lesion at c1 level of cervical spinal cord, subsequent encounter

S14.111S Complete lesion at c1 level of cervical spinal cord, sequela

S14.112A Complete lesion at c2 level of cervical spinal cord, initial encounter

S14.112D Complete lesion at c2 level of cervical spinal cord, subsequent encounter

S14.112S Complete lesion at c2 level of cervical spinal cord, sequela

S14.113A Complete lesion at c3 level of cervical spinal cord, initial encounter

S14.113D Complete lesion at c3 level of cervical spinal cord, subsequent encounter

S14.113S Complete lesion at c3 level of cervical spinal cord, sequela

S14.114A Complete lesion at c4 level of cervical spinal cord, initial encounter

S14.114D Complete lesion at c4 level of cervical spinal cord, subsequent encounter

S14.114S Complete lesion at c4 level of cervical spinal cord, sequela

S14.115A Complete lesion at c5 level of cervical spinal cord, initial encounter

S14.115D Complete lesion at c5 level of cervical spinal cord, subsequent encounter

S14.115S Complete lesion at c5 level of cervical spinal cord, sequela

S14.116A Complete lesion at c6 level of cervical spinal cord, initial encounter

S14.116D Complete lesion at c6 level of cervical spinal cord, subsequent encounter

S14.116S Complete lesion at c6 level of cervical spinal cord, sequela

S14.117A Complete lesion at c7 level of cervical spinal cord, initial encounter

S14.117D Complete lesion at c7 level of cervical spinal cord, subsequent encounter

S14.117S Complete lesion at c7 level of cervical spinal cord, sequela

S14.118A Complete lesion at c8 level of cervical spinal cord, initial encounter

S14.118D Complete lesion at c8 level of cervical spinal cord, subsequent encounter

S14.118S Complete lesion at c8 level of cervical spinal cord, sequela

S14.119A Complete lesion at unspecified level of cervical spinal cord, initial encounter

S14.119D Complete lesion at unspecified level of cervical spinal cord, subsequent encounter

S14.119S Complete lesion at unspecified level of cervical spinal cord, sequela

S14.121A Central cord syndrome at c1 level of cervical spinal cord, initial encounter

S14.121D Central cord syndrome at c1 level of cervical spinal cord, subsequent encounter

S14.121S Central cord syndrome at c1 level of cervical spinal cord, sequela

S14.122A Central cord syndrome at c2 level of cervical spinal cord, initial encounter

S14.122D Central cord syndrome at c2 level of cervical spinal cord, subsequent encounter

S14.122S Central cord syndrome at c2 level of cervical spinal cord, sequela

S14.123A Central cord syndrome at c3 level of cervical spinal cord, initial encounter

S14.123D Central cord syndrome at c3 level of cervical spinal cord, subsequent encounter

S14.123S Central cord syndrome at c3 level of cervical spinal cord, sequela

S14.124A Central cord syndrome at c4 level of cervical spinal cord, initial encounter

S14.124D Central cord syndrome at c4 level of cervical spinal cord, subsequent encounter

S14.124S Central cord syndrome at c4 level of cervical spinal cord, sequela

S14.125A Central cord syndrome at c5 level of cervical spinal cord, initial encounter

S14.125D Central cord syndrome at c5 level of cervical spinal cord, subsequent encounter

S14.125S Central cord syndrome at c5 level of cervical spinal cord, sequela

S14.126A Central cord syndrome at c6 level of cervical spinal cord, initial encounter

S14.126D Central cord syndrome at c6 level of cervical spinal cord, subsequent encounter

S14.126S Central cord syndrome at c6 level of cervical spinal cord, sequela

S14.127A Central cord syndrome at c7 level of cervical spinal cord, initial encounter

S14.127D Central cord syndrome at c7 level of cervical spinal cord, subsequent encounter

S14.127S Central cord syndrome at c7 level of cervical spinal cord, sequela

S14.128A Central cord syndrome at c8 level of cervical spinal cord, initial encounter

S14.128D Central cord syndrome at c8 level of cervical spinal cord, subsequent encounter

S14.128S Central cord syndrome at c8 level of cervical spinal cord, sequela

S14.129A Central cord syndrome at unspecified level of cervical spinal cord, initial encounter

S14.129D Central cord syndrome at unspecified level of cervical spinal cord, subsequent encounter

S14.129S Central cord syndrome at unspecified level of cervical spinal cord, sequela

S14.131A Anterior cord syndrome at c1 level of cervical spinal cord, initial encounter

S14.131D Anterior cord syndrome at c1 level of cervical spinal cord, subsequent encounter

S14.131S Anterior cord syndrome at c1 level of cervical spinal cord, sequela

S14.132A Anterior cord syndrome at c2 level of cervical spinal cord, initial encounter

S14.132D Anterior cord syndrome at c2 level of cervical spinal cord, subsequent encounter

S14.132S Anterior cord syndrome at c2 level of cervical spinal cord, sequela

S14.133A Anterior cord syndrome at c3 level of cervical spinal cord, initial encounter

S14.133D Anterior cord syndrome at c3 level of cervical spinal cord, subsequent encounter

S14.133S Anterior cord syndrome at c3 level of cervical spinal cord, sequela

S14.134A Anterior cord syndrome at c4 level of cervical spinal cord, initial encounter

S14.134D Anterior cord syndrome at c4 level of cervical spinal cord, subsequent encounter

S14.134S Anterior cord syndrome at c4 level of cervical spinal cord, sequela

S14.135A Anterior cord syndrome at c5 level of cervical spinal cord, initial encounter

S14.135D Anterior cord syndrome at c5 level of cervical spinal cord, subsequent encounter

S14.135S Anterior cord syndrome at c5 level of cervical spinal cord, sequela

S14.136A Anterior cord syndrome at c6 level of cervical spinal cord, initial encounter

S14.136D Anterior cord syndrome at c6 level of cervical spinal cord, subsequent encounter

S14.136S Anterior cord syndrome at c6 level of cervical spinal cord, sequela

S14.137A Anterior cord syndrome at c7 level of cervical spinal cord, initial encounter

S14.137D Anterior cord syndrome at c7 level of cervical spinal cord, subsequent encounter

S14.137S Anterior cord syndrome at c7 level of cervical spinal cord, sequela

S14.138A Anterior cord syndrome at c8 level of cervical spinal cord, initial encounter

S14.138D Anterior cord syndrome at c8 level of cervical spinal cord, subsequent encounter

S14.138S Anterior cord syndrome at c8 level of cervical spinal cord, sequela

S14.139A Anterior cord syndrome at unspecified level of cervical spinal cord, initial encounter

S14.139D Anterior cord syndrome at unspecified level of cervical spinal cord, subsequent encounter

S14.139S Anterior cord syndrome at unspecified level of cervical spinal cord, sequela

S14.141A Brown-sequard syndrome at c1 level of cervical spinal cord, initial encounter

S14.141D Brown-sequard syndrome at c1 level of cervical spinal cord, subsequent encounter

S14.141S Brown-sequard syndrome at c1 level of cervical spinal cord, sequela

S14.142A Brown-sequard syndrome at c2 level of cervical spinal cord, initial encounter

S14.142D Brown-sequard syndrome at c2 level of cervical spinal cord, subsequent encounter

S14.142S Brown-sequard syndrome at c2 level of cervical spinal cord, sequela

S14.143A Brown-sequard syndrome at c3 level of cervical spinal cord, initial encounter

S14.143D Brown-sequard syndrome at c3 level of cervical spinal cord, subsequent encounter

S14.143S Brown-sequard syndrome at c3 level of cervical spinal cord, sequela

S14.144A Brown-sequard syndrome at c4 level of cervical spinal cord, initial encounter

S14.144D Brown-sequard syndrome at c4 level of cervical spinal cord, subsequent encounter

S14.144S Brown-sequard syndrome at c4 level of cervical spinal cord, sequela

S14.145A Brown-sequard syndrome at c5 level of cervical spinal cord, initial encounter

S14.145D Brown-sequard syndrome at c5 level of cervical spinal cord, subsequent encounter

S14.145S Brown-sequard syndrome at c5 level of cervical spinal cord, sequela

S14.146A Brown-sequard syndrome at c6 level of cervical spinal cord, initial encounter

S14.146D Brown-sequard syndrome at c6 level of cervical spinal cord, subsequent encounter

S14.146S Brown-sequard syndrome at c6 level of cervical spinal cord, sequela

S14.147A Brown-sequard syndrome at c7 level of cervical spinal cord, initial encounter

S14.147D Brown-sequard syndrome at c7 level of cervical spinal cord, subsequent encounter

S14.147S Brown-sequard syndrome at c7 level of cervical spinal cord, sequela

S14.148A Brown-sequard syndrome at c8 level of cervical spinal cord, initial encounter

S14.148D Brown-sequard syndrome at c8 level of cervical spinal cord, subsequent encounter

S14.148S Brown-sequard syndrome at c8 level of cervical spinal cord, sequela

S14.149A Brown-sequard syndrome at unspecified level of cervical spinal cord, initial encounter

S14.149D Brown-sequard syndrome at unspecified level of cervical spinal cord, subsequent encounter

S14.149S Brown-sequard syndrome at unspecified level of cervical spinal cord, sequela

S14.151A Other incomplete lesion at c1 level of cervical spinal cord, initial encounter

S14.151D Other incomplete lesion at c1 level of cervical spinal cord, subsequent encounter

S14.151S Other incomplete lesion at c1 level of cervical spinal cord, sequela

S14.152A Other incomplete lesion at c2 level of cervical spinal cord, initial encounter

S14.152D Other incomplete lesion at c2 level of cervical spinal cord, subsequent encounter

S14.152S Other incomplete lesion at c2 level of cervical spinal cord, sequela

S14.153A Other incomplete lesion at c3 level of cervical spinal cord, initial encounter

S14.153D Other incomplete lesion at c3 level of cervical spinal cord, subsequent encounter

S14.153S Other incomplete lesion at c3 level of cervical spinal cord, sequela

S14.154A Other incomplete lesion at c4 level of cervical spinal cord, initial encounter

S14.154D Other incomplete lesion at c4 level of cervical spinal cord, subsequent encounter

S14.154S Other incomplete lesion at c4 level of cervical spinal cord, sequela

S14.155A Other incomplete lesion at c5 level of cervical spinal cord, initial encounter

S14.155D Other incomplete lesion at c5 level of cervical spinal cord, subsequent encounter

S14.155S Other incomplete lesion at c5 level of cervical spinal cord, sequela

S14.156A Other incomplete lesion at c6 level of cervical spinal cord, initial encounter

S14.156D Other incomplete lesion at c6 level of cervical spinal cord, subsequent encounter

S14.156S Other incomplete lesion at c6 level of cervical spinal cord, sequela

S14.157A Other incomplete lesion at c7 level of cervical spinal cord, initial encounter

S14.157D Other incomplete lesion at c7 level of cervical spinal cord, subsequent encounter

S14.157S Other incomplete lesion at c7 level of cervical spinal cord, sequela

S14.158A Other incomplete lesion at c8 level of cervical spinal cord, initial encounter

S14.158D Other incomplete lesion at c8 level of cervical spinal cord, subsequent encounter

S14.158S Other incomplete lesion at c8 level of cervical spinal cord, sequela

S14.159A Other incomplete lesion at unspecified level of cervical spinal cord, initial encounter

S14.159D Other incomplete lesion at unspecified level of cervical spinal cord, subsequent encounter

S14.159S Other incomplete lesion at unspecified level of cervical spinal cord, sequela

S14.2XXA Injury of nerve root of cervical spine, initial encounter

S14.2XXD Injury of nerve root of cervical spine, subsequent encounter

S14.2XXS Injury of nerve root of cervical spine, sequela

S14.3XXA Injury of brachial plexus, initial encounter

S14.3XXD Injury of brachial plexus, subsequent encounter

S14.3XXS Injury of brachial plexus, sequela

S24.0XXA Concussion and edema of thoracic spinal cord, initial encounter

S24.0XXD Concussion and edema of thoracic spinal cord, subsequent encounter

S24.0XXS Concussion and edema of thoracic spinal cord, sequela

S24.101A Unspecified injury at t1 level of thoracic spinal cord, initial encounter

S24.101D Unspecified injury at t1 level of thoracic spinal cord, subsequent encounter

S24.101S Unspecified injury at t1 level of thoracic spinal cord, sequela

S24.102A Unspecified injury at t2-t6 level of thoracic spinal cord, initial encounter

S24.102D Unspecified injury at t2-t6 level of thoracic spinal cord, subsequent encounter

S24.102S Unspecified injury at t2-t6 level of thoracic spinal cord, sequela

S24.103A Unspecified injury at t7-t10 level of thoracic spinal cord, initial encounter

S24.103D Unspecified injury at t7-t10 level of thoracic spinal cord, subsequent encounter

S24.103S Unspecified injury at t7-t10 level of thoracic spinal cord, sequela

S24.104A Unspecified injury at t11-t12 level of thoracic spinal cord, initial encounter

S24.104D Unspecified injury at t11-t12 level of thoracic spinal cord, subsequent encounter

S24.104S Unspecified injury at t11-t12 level of thoracic spinal cord, sequela

S24.109A Unspecified injury at unspecified level of thoracic spinal cord, initial encounter

S24.109D Unspecified injury at unspecified level of thoracic spinal cord, subsequent encounter

S24.109S Unspecified injury at unspecified level of thoracic spinal cord, sequela

S24.111A Complete lesion at t1 level of thoracic spinal cord, initial encounter

S24.111D Complete lesion at t1 level of thoracic spinal cord, subsequent encounter

S24.111S Complete lesion at t1 level of thoracic spinal cord, sequela

S24.112A Complete lesion at t2-t6 level of thoracic spinal cord, initial encounter

S24.112D Complete lesion at t2-t6 level of thoracic spinal cord, subsequent encounter

S24.112S Complete lesion at t2-t6 level of thoracic spinal cord, sequela

S24.113A Complete lesion at t7-t10 level of thoracic spinal cord, initial encounter

S24.113D Complete lesion at t7-t10 level of thoracic spinal cord, subsequent encounter

S24.113S Complete lesion at t7-t10 level of thoracic spinal cord, sequela

S24.114A Complete lesion at t11-t12 level of thoracic spinal cord, initial encounter

S24.114D Complete lesion at t11-t12 level of thoracic spinal cord, subsequent encounter

S24.114S Complete lesion at t11-t12 level of thoracic spinal cord, sequela

S24.119A Complete lesion at unspecified level of thoracic spinal cord, initial encounter

S24.119D Complete lesion at unspecified level of thoracic spinal cord, subsequent encounter

S24.119S Complete lesion at unspecified level of thoracic spinal cord, sequela

S24.131A Anterior cord syndrome at t1 level of thoracic spinal cord, initial encounter

S24.131D Anterior cord syndrome at t1 level of thoracic spinal cord, subsequent encounter

S24.131S Anterior cord syndrome at t1 level of thoracic spinal cord, sequela

S24.132A Anterior cord syndrome at t2-t6 level of thoracic spinal cord, initial encounter

S24.132D Anterior cord syndrome at t2-t6 level of thoracic spinal cord, subsequent encounter

S24.132S Anterior cord syndrome at t2-t6 level of thoracic spinal cord, sequela

S24.133A Anterior cord syndrome at t7-t10 level of thoracic spinal cord, initial encounter

S24.133D Anterior cord syndrome at t7-t10 level of thoracic spinal cord, subsequent encounter

S24.133S Anterior cord syndrome at t7-t10 level of thoracic spinal cord, sequela

S24.134A Anterior cord syndrome at t11-t12 level of thoracic spinal cord, initial encounter

S24.134D Anterior cord syndrome at t11-t12 level of thoracic spinal cord, subsequent encounter

S24.134S Anterior cord syndrome at t11-t12 level of thoracic spinal cord, sequela

S24.139A Anterior cord syndrome at unspecified level of thoracic spinal cord, initial encounter

S24.139D Anterior cord syndrome at unspecified level of thoracic spinal cord, subsequent encounter

S24.139S Anterior cord syndrome at unspecified level of thoracic spinal cord, sequela

S24.141A Brown-sequard syndrome at t1 level of thoracic spinal cord, initial encounter

S24.141D Brown-sequard syndrome at t1 level of thoracic spinal cord, subsequent encounter

S24.141S Brown-sequard syndrome at t1 level of thoracic spinal cord, sequela

S24.142A Brown-sequard syndrome at t2-t6 level of thoracic spinal cord, initial encounter

S24.142D Brown-sequard syndrome at t2-t6 level of thoracic spinal cord, subsequent encounter

S24.142S Brown-sequard syndrome at t2-t6 level of thoracic spinal cord, sequela

S24.143A Brown-sequard syndrome at t7-t10 level of thoracic spinal cord, initial encounter

S24.143D Brown-sequard syndrome at t7-t10 level of thoracic spinal cord, subsequent encounter

S24.143S Brown-sequard syndrome at t7-t10 level of thoracic spinal cord, sequela

S24.144A Brown-sequard syndrome at t11-t12 level of thoracic spinal cord, initial encounter

S24.144D Brown-sequard syndrome at t11-t12 level of thoracic spinal cord, subsequent encounter

S24.144S Brown-sequard syndrome at t11-t12 level of thoracic spinal cord, sequela

S24.149A Brown-sequard syndrome at unspecified level of thoracic spinal cord, initial encounter

S24.149D Brown-sequard syndrome at unspecified level of thoracic spinal cord, subsequent encounter

S24.149S Brown-sequard syndrome at unspecified level of thoracic spinal cord, sequela

S24.151A Other incomplete lesion at t1 level of thoracic spinal cord, initial encounter

S24.151D Other incomplete lesion at t1 level of thoracic spinal cord, subsequent encounter

S24.151S Other incomplete lesion at t1 level of thoracic spinal cord, sequela

S24.152A Other incomplete lesion at t2-t6 level of thoracic spinal cord, initial encounter

S24.152D Other incomplete lesion at t2-t6 level of thoracic spinal cord, subsequent encounter

S24.152S Other incomplete lesion at t2-t6 level of thoracic spinal cord, sequela

S24.153A Other incomplete lesion at t7-t10 level of thoracic spinal cord, initial encounter

S24.153D Other incomplete lesion at t7-t10 level of thoracic spinal cord, subsequent encounter

S24.153S Other incomplete lesion at t7-t10 level of thoracic spinal cord, sequela

S24.154A Other incomplete lesion at t11-t12 level of thoracic spinal cord, initial encounter

S24.154D Other incomplete lesion at t11-t12 level of thoracic spinal cord, subsequent encounter

S24.154S Other incomplete lesion at t11-t12 level of thoracic spinal cord, sequela

S24.159A Other incomplete lesion at unspecified level of thoracic spinal cord, initial encounter

S24.159D Other incomplete lesion at unspecified level of thoracic spinal cord, subsequent encounter

S24.159S Other incomplete lesion at unspecified level of thoracic spinal cord, sequela

S24.2XXA Injury of nerve root of thoracic spine, initial encounter

S24.2XXD Injury of nerve root of thoracic spine, subsequent encounter

S24.2XXS Injury of nerve root of thoracic spine, sequela

S34.01XA Concussion and edema of lumbar spinal cord, initial encounter

S34.01XD Concussion and edema of lumbar spinal cord, subsequent encounter

S34.01XS Concussion and edema of lumbar spinal cord, sequela

S34.02XA Concussion and edema of sacral spinal cord, initial encounter

S34.02XD Concussion and edema of sacral spinal cord, subsequent encounter

S34.02XS Concussion and edema of sacral spinal cord, sequela

S34.101A Unspecified injury to l1 level of lumbar spinal cord, initial encounter

S34.101D Unspecified injury to l1 level of lumbar spinal cord, subsequent encounter

S34.101S Unspecified injury to l1 level of lumbar spinal cord, sequela

S34.102A Unspecified injury to l2 level of lumbar spinal cord, initial encounter

S34.102D Unspecified injury to l2 level of lumbar spinal cord, subsequent encounter

S34.102S Unspecified injury to l2 level of lumbar spinal cord, sequela

S34.103A Unspecified injury to l3 level of lumbar spinal cord, initial encounter

S34.103D Unspecified injury to l3 level of lumbar spinal cord, subsequent encounter

S34.103S Unspecified injury to l3 level of lumbar spinal cord, sequela

S34.104A Unspecified injury to l4 level of lumbar spinal cord, initial encounter

S34.104D Unspecified injury to l4 level of lumbar spinal cord, subsequent encounter

S34.104S Unspecified injury to l4 level of lumbar spinal cord, sequela

S34.105A Unspecified injury to l5 level of lumbar spinal cord, initial encounter

S34.105D Unspecified injury to l5 level of lumbar spinal cord, subsequent encounter

S34.105S Unspecified injury to l5 level of lumbar spinal cord, sequela

S34.109A Unspecified injury to unspecified level of lumbar spinal cord, initial encounter

S34.109D Unspecified injury to unspecified level of lumbar spinal cord, subsequent encounter

S34.109S Unspecified injury to unspecified level of lumbar spinal cord, sequela

S34.111A Complete lesion of l1 level of lumbar spinal cord, initial encounter

S34.111D Complete lesion of l1 level of lumbar spinal cord, subsequent encounter

S34.111S Complete lesion of l1 level of lumbar spinal cord, sequela

S34.112A Complete lesion of l2 level of lumbar spinal cord, initial encounter

S34.112D Complete lesion of l2 level of lumbar spinal cord, subsequent encounter

S34.112S Complete lesion of l2 level of lumbar spinal cord, sequela

S34.113A Complete lesion of l3 level of lumbar spinal cord, initial encounter

S34.113D Complete lesion of l3 level of lumbar spinal cord, subsequent encounter

S34.113S Complete lesion of l3 level of lumbar spinal cord, sequela

S34.114A Complete lesion of l4 level of lumbar spinal cord, initial encounter

S34.114D Complete lesion of l4 level of lumbar spinal cord, subsequent encounter

S34.114S Complete lesion of l4 level of lumbar spinal cord, sequela

S34.115A Complete lesion of l5 level of lumbar spinal cord, initial encounter

S34.115D Complete lesion of l5 level of lumbar spinal cord, subsequent encounter

S34.115S Complete lesion of l5 level of lumbar spinal cord, sequela

S34.119A Complete lesion of unspecified level of lumbar spinal cord, initial encounter

S34.119D Complete lesion of unspecified level of lumbar spinal cord, subsequent encounter

S34.119S Complete lesion of unspecified level of lumbar spinal cord, sequela

S34.121A Incomplete lesion of l1 level of lumbar spinal cord, initial encounter

S34.121D Incomplete lesion of l1 level of lumbar spinal cord, subsequent encounter

S34.121S Incomplete lesion of l1 level of lumbar spinal cord, sequela

S34.122A Incomplete lesion of l2 level of lumbar spinal cord, initial encounter

S34.122D Incomplete lesion of l2 level of lumbar spinal cord, subsequent encounter

S34.122S Incomplete lesion of l2 level of lumbar spinal cord, sequela

S34.123A Incomplete lesion of l3 level of lumbar spinal cord, initial encounter

S34.123D Incomplete lesion of l3 level of lumbar spinal cord, subsequent encounter

S34.123S Incomplete lesion of l3 level of lumbar spinal cord, sequela

S34.124A Incomplete lesion of l4 level of lumbar spinal cord, initial encounter

S34.124D Incomplete lesion of l4 level of lumbar spinal cord, subsequent encounter

S34.124S Incomplete lesion of l4 level of lumbar spinal cord, sequela

S34.125A Incomplete lesion of l5 level of lumbar spinal cord, initial encounter

S34.125D Incomplete lesion of l5 level of lumbar spinal cord, subsequent encounter

S34.125S Incomplete lesion of l5 level of lumbar spinal cord, sequela

S34.129A Incomplete lesion of unspecified level of lumbar spinal cord, initial encounter

S34.129D Incomplete lesion of unspecified level of lumbar spinal cord, subsequent encounter

S34.129S Incomplete lesion of unspecified level of lumbar spinal cord, sequela

S34.131A Complete lesion of sacral spinal cord, initial encounter

S34.131D Complete lesion of sacral spinal cord, subsequent encounter

S34.131S Complete lesion of sacral spinal cord, sequela

S34.132A Incomplete lesion of sacral spinal cord, initial encounter

S34.132D Incomplete lesion of sacral spinal cord, subsequent encounter

S34.132S Incomplete lesion of sacral spinal cord, sequela

S34.139A Unspecified injury to sacral spinal cord, initial encounter

S34.139D Unspecified injury to sacral spinal cord, subsequent encounter

S34.139S Unspecified injury to sacral spinal cord, sequela

S34.21XA Injury of nerve root of lumbar spine, initial encounter

S34.21XD Injury of nerve root of lumbar spine, subsequent encounter

S34.21XS Injury of nerve root of lumbar spine, sequela

S34.22XA Injury of nerve root of sacral spine, initial encounter

S34.22XD Injury of nerve root of sacral spine, subsequent encounter

S34.22XS Injury of nerve root of sacral spine, sequela

S34.3XXA Injury of cauda equina, initial encounter

S34.3XXD Injury of cauda equina, subsequent encounter

S34.3XXS Injury of cauda equina, sequela

S34.4XXA Injury of lumbosacral plexus, initial encounter

S34.4XXD Injury of lumbosacral plexus, subsequent encounter

S34.4XXS Injury of lumbosacral plexus, sequela

REMOVAL/REVISION OF SPINAL CORD STIMULATION DEVICES ARE MEDICALLY NECESSARY WITH THE FOLLOWING DIAGNOSIS CODES

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

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

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

T85.118A Breakdown (mechanical) of other implanted electronic stimulator of nervous system, initial encounter

T85.118D Breakdown (mechanical) of other implanted electronic stimulator of nervous system, subsequent encounter

T85.118S Breakdown (mechanical) of other implanted electronic stimulator of nervous system, sequela

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

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

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

T85.128A Displacement of other implanted electronic stimulator of nervous system, initial encounter

T85.128D Displacement of other implanted electronic stimulator of nervous system, subsequent encounter

T85.128S Displacement of other implanted electronic stimulator of nervous system, sequela

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

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

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

T85.193A Other mechanical complication of implanted electronic neurostimulator, generator, initial encounter

T85.193D Other mechanical complication of implanted electronic neurostimulator, generator, subsequent encounter

T85.193S Other mechanical complication of implanted electronic neurostimulator, generator, sequela

T85.199A Other mechanical complication of other implanted electronic stimulator of nervous system, initial encounter

T85.199D Other mechanical complication of other implanted electronic stimulator of nervous system, subsequent encounter

T85.199S Other mechanical complication of other implanted electronic stimulator of nervous system, sequela

T85.733A Infection and inflammatory reaction due to implanted electronic neurostimulator of spinal cord, electrode (lead), initial encounter

T85.733D Infection and inflammatory reaction due to implanted electronic neurostimulator of spinal cord, electrode (lead), subsequent encounter

T85.733S Infection and inflammatory reaction due to implanted electronic neurostimulator of spinal cord, electrode (lead), sequela

T85.734A Infection and inflammatory reaction due to implanted electronic neurostimulator, generator, initial encounter

T85.734D Infection and inflammatory reaction due to implanted electronic neurostimulator, generator, subsequent encounter

T85.734S Infection and inflammatory reaction due to implanted electronic neurostimulator, generator, sequela

T85.79XA Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter

T85.79XD Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, subsequent encounter

T85.79XS Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, sequela

T85.840A Pain due to nervous system prosthetic devices, implants and grafts, initial encounter

T85.840D Pain due to nervous system prosthetic devices, implants and grafts, subsequent encounter

T85.840S Pain due to nervous system prosthetic devices, implants and grafts, sequela

Z45.42 Encounter for adjustment and management of neuropacemaker (brain) (peripheral nerve) (spinal cord)



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


Cross References


Policy History

Revisions from 11.15.01u:
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 11.15.01t:
07/02/2018This version of the policy will become effective on 07/02/2018.

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

ICD-10 codes have been added back to this policy bulletin.

Revisions from 11.15.01s:
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.

Effective 10/05/2017 this policy has been updated to the new policy template
format.


Effective 10/05/2017 this policy has been updated to the new policy template format.


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

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