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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 02/01/2012 Title: Cord Neurostimulation for Treatment of Intractable Pain
Revision Date: Document: BI323:00
CPT Code(s): 63650, 63655, 63660, 63685, 63688, 95970, 95971, 95972, L8680, L8685, L8686, L8687, L8688
  1. Implantation of spinal cord neurostimulator requires pre-authorization.
  2. Spinal cord neurostimulator is used to treat severe pain that does not respond to other measures.

1)    Implantation of spinal neurostimulators is considered medically necessary for the control of severe and chronic pain of the trunk or limbs that is refractory to all other pain therapies.  

 

2)    Implantation of dorsal column stimulators or services and supplies related to such implantation is covered when the following criteria are met:

a)     The implantation of the stimulator is used only as a last resort for members with chronic intractable pain;

b)     Other treatment modalities (pharmacological, surgical, physical, or psychological therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for the given member;

c)     The members have undergone careful screening, evaluation and diagnosis by a multi-disciplinary team prior to implantation.  (Such screening must include psychological, as well as physical evaluation.  Psychological evaluation must demonstrate that the member is a suitable candidate);

d)     All the facilities, equipment and professional and support personnel required for the proper diagnosis, treatment training and follow-up of the member (including that required to satisfy the requirement above), must be available; and

e)     Pain relief has been demonstrated after a trial with a temporary implanted electrode.  (Demonstration of pain relief over at least a three day interval between the placement of the temporary electrode and the permanent electrode is required.)  Once treatment effectiveness is established (at least 59% reduction in pain), the electrodes and radio-receiver/transducer are permanently implanted.

  

3)    Implantation of spinal neurostimulators for members with documented metastatic malignant disease, who have a life expectancy of at least six months, is covered when above criteria are met, with the exception of psychological testing which would not be required.

 

4)    Implantation of spinal neurostimulators is covered for members with severe angina when the risks of surgery are deemed too high and standard medical therapy options have been exhausted and above criteria are met, with the exception of psychological testing which would not be required.

 

5)    If the member has had the neurostimulator in place, and the member is experiencing satisfactory reduction in pain, and the member requires revision or removal of the spinal neurostimulator electrodes and/or revision or removal of the implanted spinal neurostimulator pulse generator or receiver, the member does not have to undergo a trial period or any further psychological testing.

 

6)    If the member has placement of the temporary electrode, but the trial period indicates the member will not benefit from the placement of the permanent electrode, the physician should bill CPT 63650 for the percutaneous implantation of neurostimulator electrodes, epidural, only.

 

7)    If the member has placement of the percutaneous implantation of the neurostimulator electrodes, epidural, for the trial period, and the treatment is effective, then the physician should bill CPT 63650 for the placement of that electrode, and CPT 63685 for the incision and subcutaneous placement of the spinal neurostimulator pulse generator or receiver.

 

8)    If the placement of the electrode is done by laminectomy, then CPT 63655 is billed for the placement and CPT 63685 for the incision and subcutaneous placement of the spinal neurostimulator pulse generator or receiver.

 

Codes Used In This BI:

63650

Percutaneous implantation of neurostimulator electrode array, epidural

63655

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

63660

Revision or removal of spinal neurostimulator electrode percutaneous array(s) or plate/paddle(s)

63685

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

63688

Revision or removal of implanted spinal neurostimulator pulse generator or receiver

95970

Electronic analysis of implanted neurostimulator pulse generator system ..., without reprogramming

95971

Electronic analysis of implanted neurostimulator pulse generator system ... with intraoperative or subsequent programming

95972

Electronic analysis of implanted neurostimulator pulse generator ... with intraoperative or subsequent programming, first hour

L8680

Implantable neurostimulator electrode, each

L8685

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

L8686

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

L8687

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

L8688

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

Burchiel KJ, Anderson VC, Brown FD et al.(1996) Prospective, multicenter study of spinal cord stimulation for relief of chronic back and extremity pain. Spine 1996; 21(23):2786-94.

Cruccu G, Aziz TZ, et al.(2007) EFNS guidelines on neurostimulation therapy for neuropathic pain. Eur J Neurol, 2007; 14:952-70.

Deer TR.(2001) Current and future trends in spinal cord stimulation for chronic pain. Curr Pain Headache Rep 2001; 5:503-9.

Kay AD, McIntyre MD, Macrae WA, et al.(2001) Spinal cord stimulation - a long-term evaluation in patients with chronic pain. Br J Neurosurg 2001; 15:335-41.

Kemler MA, Barendse GA, van Kleef M, et al.(2000) Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy. NEJM 2000; 343(9):618-24.

Kemler MA, De Vet HC, Barendse GA, et al.(2004) The effect of spinal cord stimulation in patients with chronic reflex sympathetic dystrophy: two years` follow-up of the randomized controlled trial. Annals Neurology 2004; 55(1):13-8.

Kemler MA, De Vet HC, Barendse GA, et al.(2004) The effect of spinal cord stimulation in patients with chronic reflex sympathetic dystrophy: two years’ follow-up of the randomized controlled trial. Ann Neurol 2004; 55(1):13-8.

Kemler MA, de Vet HC, et al.(2008) Effection of spinal cord stimulation for chronic complex regional pain syndrome Type I: five-year final follow-up of patients in a randomized controlled trial. J Neurosurg, 2008; 108:292-8.

Klomp HM, Spincemaille GH, Steyerberg EW, et al.(1999) Spinal cord stimulation in critical limb ischemia: a randomized trial. Lancet 1999; 353(9158):1040-4.

Lapenna E, Papati D, et al.(2006) Spinal cord stimulation for patients with refractory angina and previous coronary surgery. Ann Thor Surg, 2006; 82:1704-8.

Mailis-Gagnon A, Furlan AD, Sandoval JA, et al.(2004) Spinal cord stimulation for chronic pain. The Cochrane Database Systematic Reviews, Issue 3, Art. No. CD003783.pub2; 2004.

Meyerson BA.(2001) Neurosurgical approaches to pain treatment. Acta Anaesthesiol Scand 2001; 45:1108-13.
North R, Shipley J, et al.(2007) Practice parameters for the use of spinal cord stimulation in the treatment of chronic neuropathic pain. Pain Med, 2007; 8:S200-S275.

North RB, Calkins SK, Campbell DS, et al.(2003) Automated, patient-interactive, spinal cord stimulator adjustment: a randomized controlled trial. Nuerosurgery 2003; 52(3):572-80.

North RB, et al.(1993) Sperm function assays and their predictive value for fertilization outcome in IVF therapy: a meta-analysis. Neurosurg 1993; 32:384-395.

North RB, Kidd DH, Lee MS et al.(1994) A prospective, randomized study of spinal cord stimulation versus reoperation for failed back surgery syndrome: initial results. Stereotact Funct Neurosurg 1994; 62(1-4):267-72.

The British Pain Society.(2005) Spinal cord stimulation for the management of chronic pain. Recommendations for best clinical practice. http://britishpainsociety.org, accessed Feb 2007.

Turner JA, Loeser JD, Bell KG.(1995) Spinal cord stimulation for chronic low back pain: a systematic literature synthesis. Neurosurgery 1995; 37(6):1088-96.

Ubbink DT, Vermeulen H.(2003) Spinal cord stimulation for non-reconsdtructable chronic critical leg ischaemia. The Cochrane Database Systematic Reviews 2003, Issue 3, Art NO. CD004001.

 

This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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