Spinal cord stimulation blocks pain conduction pathways to the brain and may stimulate endorphins. The neurostimulator electrodes used for this purpose are implanted percutaneously in the epidural space through a special needle. Some patients may need an open procedure requiring laminectomy to place the electrodes.
After placement of the electrodes, the patient is provided with an external neurostimulator, initially on a trial basis. The trial period may be extended up to four weeks. If during the trial period it is determined that the modality is not effective, or it is not acceptable to the patient, the electrodes may be removed.
If the trial has been successful, a spinal neurostimulator and pulse generator are inserted subcutaneously and connected to the implanted electrodes. In some cases, the trial may be conducted using temporary electrodes.
Indications
Dorsal column stimulators may be covered as therapies for the relief of chronic intractable pain under the following circumstances:
- To treat chronic pain caused by lumbosacral arachnoiditis that has not responded to medical management including physical therapy. (Presence of arachnoiditis is usually documented by presence of high levels of proteins in the Cerebrospinal Fluid (CSF) and/or by myelography or Magnetic Resonance Imaging (MRI).)
- To treat intractable pain caused by nerve root injuries, post-surgical or post-traumatic including that of post-laminectomy syndrome (failed back syndrome).
- To treat intractable pain caused by complex regional pain syndrome I & II.
- To treat intractable pain caused by phantom limb syndrome that has not responded to medical management.
- To treat intractable pain caused by end-stage peripheral vascular disease, when the patient cannot undergo revascularization or when revascularization has failed to relieve painful symptoms and the pain has not responded to medical management.
- To treat intractable pain caused by post-herpetic neuralgia.
- To treat intractable pain caused by plexopathy.
- To treat intractable pain caused by intercostal neuralgia that did not respond to medical management and nerve blocks.
- To treat intractable pain caused by cauda equina injury.
- To treat intractable pain caused by incomplete spinal cord injury.
Limitations
No payment may be made for the implantation of dorsal column stimulators or services and supplies related to such implantation, unless all of the following conditions have been met:
- The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic intractable pain.
- Other treatment modalities (pharmacological, surgical, physical or psychological therapies) have been tried and did not prove satisfactory or are judged unsuitable or contraindicated for the given patient.
- Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation (such screening must include psychological as well as physical evaluation).
- All facilities, equipment and personnel required for the proper diagnosis, treatment, training and follow-up of the patient must be available.
- Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation.
Generally, electronic analysis services (CPT codes 95970–95973) are not considered medically necessary when provided at a frequency more often than once every 30 days. More frequent analysis may be necessary in the first month after implantation.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
13X, 83X, 85X
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances, Revenue Codes are purely advisory; unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD . Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/orRevenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Publication 100-04, Claims Processing Manual, or further guidance.
036X
CPT/HCPCS Codes
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Note:
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Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
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63650©
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Implant neuroelectrodes
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63655©
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Implant neuroelectrodes
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63661©
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Remove spine eltrd perq aray
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63662©
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Remove spine eltrd plate
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63663©
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Revise spine eltrd perq aray
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63664©
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Revise spine eltrd plate
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63685©
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Insrt/redo spine n generator
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95970©
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Analyze neurostim, no prog
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95971©
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Analyze neurostim, simple
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95972©
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Analyze neurostim, complex
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95973©
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Analyze neurostim, complex
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L8680
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Implt neurostim elctr each
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L8681
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Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only
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L8682
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Implantable neurostimulator radiofrequency receiver
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L8683
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Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
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L8685
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Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
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L8686
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Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
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L8687
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Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
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L8688
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Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension
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L8689
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External recharging system for battery (internal) for use with implantable neurostimulator, replacement only
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L8695
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External recharging system for battery (external) for use with implantable neurostimulator, replacement only
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L8699
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Prosthetic implant, not otherwise specified
Note: Use L8699 to bill for trial stimulator
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ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Dual diagnosis requirement: Claims submitted for spinal cord stimulation must include both a primary ICD-9-CMdiagnosis code indicating the reason for the procedure and a secondary ICD-9-CM diagnosis code indicating the etiology of the chronic pain.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 63650, 63655 and 63685:
Primary Diagnosis Codes
Covered for:
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338.21
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Chronic pain due to trauma
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338.28
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Other chronic postoperative pain
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338.3
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Neoplasm related pain (acute) (chronic)
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338.4
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Chronic pain syndrome
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Secondary Diagnosis Codes
Covered for:
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053.12
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Postherpetic trigeminal neuralgia
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053.19
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Herpes zoster; with other nervous system complications, other
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322.9
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Meningitis, unspecified
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337.21–337.22
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Reflex sympathetic dystrophy
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337.29
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Reflex sympathetic dystrophy of other specified site
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353.0–353.1
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Nerve root and plexus disorders
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353.6
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Nerve root and plexus disorders; phantom limb (syndrome)
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353.8
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Nerve root and plexus disorders; other nerve root and plexus disorder
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354.4
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Causalgia of upper limb
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354.8–354.9
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Mononeuritis of upper limb and mononeuritis multiplex
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355.71
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Causalgia of lower limb
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355.79
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Other mononeuritis of lower limb
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355.8
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Mononeuritis of lower limb, unspecified
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440.22
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Atherosclerosis of the extremities with rest pain
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722.81–722.83
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Postlaminectomy syndrome
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723.4
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Brachial neuritis or radiculitis NOS
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724.3–724.4
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Other and unspecified disorders of back
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952.00–952.09
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Spinal cord injury without evidence of spinal bone injury, cervical
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952.10–952.19
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Spinal cord injury without evidence of spinal bone injury, dorsal (thoracic)
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952.2–952.4
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Spinal cord injury without evidence of spinal bone injury
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952.8–952.9
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Spinal cord injury without evidence of spinal bone injury
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953.0–953.5
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Injury to nerve roots and spinal plexus
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953.8–953.9
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Injury to nerve roots and spinal plexus
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Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Note: HCPCS Codes L8680, L8681, L8682, L8683, L8685, L8686, L8687, L8688, L8689, L8695 and L8699 are used for various other services. Medicare is not establishing limited coverage for these codes at this time.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
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296.00–296.06
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Bipolar I disorder, single manic episode
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296.10–296.16
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Manic disorder, recurrent disorder
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296.20–296.26
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Major depressive disorder, single episode
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296.30–296.36
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Major depressive disorder, recurrent episode
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296.40–296.46
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Bipolar I disorder, most recent episode (or current) manic
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296.50–296.56
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Bipolar I disorder, most recent episode (or current) depressed
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296.60–296.66
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Bipolar I disorder, most recent episode (or current) mixed
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296.7
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Bipolar I disorder, most recent episode (or current) unspecified
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296.80–296.82
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Other and unspecified bipolar disorders
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296.89
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Other and unspecified bipolar disorders
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296.90
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Unspecified episodic mood disorder
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296.99
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Other specified episodic mood disorder
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298.0
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Depressive type psychosis
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300.4
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Dysthymic disorder
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309.0
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Adjustment disorder with depressed mood
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309.1
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Prolonged depressive reaction
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311
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Depressive disorder, not elsewhere classified
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Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
For CPT codes 63663© (revise spine eltrd perq array) and 63664© (revise spine eltrd plate), documentation must include the date the initial insertion was performed.
Appendices
N/A
