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Medical and Behavioral Health Policy
Section: Medicine
Policy Number: II-149
Effective Date: 05/27/2015
Blue Cross and Blue Shield of Minnesota medical policies do not imply that members should not receive specific services
based on the recommendation of their provider. These policies govern coverage and not clinical practice. Providers are
responsible for medical advice and treatment of patients. Members with specific health care needs should consult an
appropriate health care professional.
PERIPHERAL NERVE STIMULATION
OF THE TRUNK OR LIMBS FOR TREATMENT OF PAIN
Description:
Chronic non-cancer pain is managed with a range of
pharmacological, physical, psychological and surgical modalities.
Peripheral nerve stimulation or neuromodulation has been proposed
as a non-destructive surgical option for patients with refractory
neuropathic pain affecting the trunk or limbs.
Use of a peripheral nerve stimulator involves implantation of
electrodes around a selected peripheral nerve (e.g., radial, sciatic,
ileoinguinal). The stimulating electrode is connected by an insulated
lead to a receiver unit which is implanted under the skin at a depth
not greater than 1/2 inch. Stimulation is induced by a generator
connected to an antenna unit which is attached to the skin surface
over the receiver unit.
As with other types of implantable nerve stimulation, implantation of
the peripheral nerve stimulator is typically a two-step process.
Initially, the electrode is temporarily implanted, allowing a trial period
of stimulation. Once treatment effectiveness is confirmed (defined as
at least 50% reduction in pain), the electrodes and radio-receiver/
transducer are permanently implanted.
Peripheral nerve (regional) field stimulation is a relatively recent
application of peripheral neuromodulation. This type of stimulation,
which involves placement of a stimulating electrode subcutaneously
in the area of maximum pain, has been proposed as a treatment of
low back pain.
The implantable stimulation system used for PNS (i.e., generator,
electrodes, leads) includes basically the same components used for
spinal cord stimulation. Although the surgical leads used for PNS
have received 510(k) marketing clearance for peripheral nerve
stimulation for treatment of intractable chronic pain, no complete
stimulation system has received FDA approval for treatment of
specific nerves.
NOTE: Occipital Nerve Stimulation is addressed separately in
policy II-140.
Policy:
Peripheral nerve stimulation of the trunk or limbs, including but not
limited to stimulation of the radial, sciatic, and ileoinguinal nerves, is
considered INVESTIGATIVE for the treatment of all acute and
chronic pain indications due to a lack of evidence demonstrating its
impact on improved health outcomes.
Peripheral nerve (regional) field stimulation is considered
INVESTIGATIVE for the treatment of chronic pain due to a lack of
evidence demonstrating its impact on improved health outcomes.
Coverage:
Blue Cross and Blue Shield of Minnesota medical policies apply
generally to all Blue Cross and Blue Plus plans and products. Benefit
plans vary in coverage and some plans may not provide coverage
for certain services addressed in the medical policies.
Medicaid products and some self-insured plans may have additional
policies and prior authorization requirements. Receipt of benefits is
subject to all terms and conditions of the member’s summary plan
description (SPD). As applicable, review the provisions relating to a
specific coverage determination, including exclusions and limitations.
Blue Cross reserves the right to revise, update and/or add to its
medical policies at any time without notice.
For Medicare NCD and/or Medicare LCD, please consult CMS or
National Government Services websites.
Refer to the Pre-Certification/Pre-Authorization section of the
Medical Behavioral Health Policy Manual for the full list of services,
procedures, prescription drugs, and medical devices that require
Pre-certification/Pre-Authorization. Note that services with specific
coverage criteria may be reviewed retrospectively to determine if
criteria are being met. Retrospective denial of claims may result if
criteria are not met.
Coding:
The following codes are included below for informational purposes
only, and are subject to change without notice. Inclusion or exclusion
of a code does not constitute or imply member coverage or provider
reimbursement.
CPT:
64555 Percutaneous implantation of neurostimulator electrode array;
peripheral nerve (excludes sacral nerve)
64575 Incision for implantation of neurostimulator electrode array;
peripheral nerve (excludes sacral nerve)
64595 Revision or removal of peripheral or gastric neurostimulator
pulse generator or receiver
0282T Percutaneous or open implantation of neurostimulator
electrode array(s), subcutaneous (peripheral subcutaneous field
stimulation), including imaging guidance, when performed, cervical,
thoracic or lumbar; for trial, including removal at the conclusion of
trial period
0283T Percutaneous or open implantation of neurostimulator
electrode array(s), subcutaneous (peripheral subcutaneous field
stimulation), including imaging guidance, when performed, cervical,
thoracic or lumbar; permanent, with implantation of a pulse generator
HCPCS:
L8679 Implantable neurostimulator, pulse generator, any type
L8680 Implantable neurostimulator electrode, each
L8682 Implantable neurostimulator radiofrequency receiver
L8683 Radiofrequency transmitter (external) for use with implantable
neurostimulator radiofrequency receiver
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, nonrechargeable, includes extension
Policy
History:
Developed April 13, 2011
Most recent history:
Reviewed April 11, 2012
Reviewed April 10, 2013
Reviewed May 14, 2014
Reviewed May 13, 2015
Cross
Reference:
Occipital Nerve Stimulation, II-140
Spinal Cord Stimulation, IV-74
Current Procedural Terminology (CPT®) is copyright 2014 American Medical
Association. All Rights Reserved. No fee schedules, basic units, relative values, or
related listings are included in CPT. The AMA assumes no liability for the data
contained herein. Applicable FARS/DFARS restrictions apply to government use.
Copyright 2015 Blue Cross Blue Shield of Minnesota.