Clinical UM Guideline

 

Subject: Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)
Guideline #: CG-SURG-66 Publish Date:    12/27/2017
Status: New Last Review Date:    11/02/2017

Description

 

This document addresses the use of implantable neurostimulation techniques including spinal cord stimulators and subcutaneous target stimulation (also known as peripheral subcutaneous field stimulation).

 

Clinical Indications

Medically Necessary:

A temporarily implanted epidural spinal cord stimulator for the treatment of chronic (greater than 6 month duration) intractable neuropathic pain is considered medically necessary when all of the following criteria are met:

  1. Documentation in the medical record of the failure of 6 months of conservative treatment modalities (pharmacologic, surgical, psychologic or physical), if appropriate and not contraindicated; and
  2. Further surgical intervention is not indicated; and
  3. Psychological evaluation has been obtained and there is documentation that there are no inadequately controlled mental health problems (including but not limited to alcohol or drug dependence, depression, or psychogenic pain); and
  4. No contraindications to implantation exist such as sepsis or coagulopathy; and
  5. Objective documentation of pathology in the medical record.

A permanently implanted epidural spinal cord stimulator for the treatment of chronic (greater than 6 month duration) intractable neuropathic pain is considered medically necessary when a temporary trial of spinal cord stimulation has been successful. Successful is defined as:

  1. 50% reduction in pain for at least 2 days; and
  2. Improvement in function documented in the medical record; and
  3. The permanent electrodes are placed in the same spinal region(s) where the temporary trial produced relief (example, trial in lumbar region results in permanent electrode placement in lumbar region).

Not Medically Necessary:

Implantable epidural spinal cord stimulators for the treatment of chronic intractable neuropathic pain that do not meet all the applicable criteria listed as medically necessary are considered not medically necessary.

Treatment of all other diseases and disorders, including but not limited to thalamic pain syndromes, by an implanted epidural spinal cord stimulator (both temporary and permanent) is considered not medically necessary.

Implantable epidural spinal cord stimulation (both temporary and permanent) is considered not medically necessary as a treatment of critical limb ischemia as a technique to forestall amputation.

Implantable subcutaneous target stimulator devices (both temporary and permanent) are considered not medically necessary for all indications.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

63650

Percutaneous implantation of neurostimulator electrode array, epidural

63655

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

63685

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

64999

Unlisted procedure, nervous system [when specified as implantation of trial or permanent electrode arrays or pulse generators for peripheral subcutaneous field stimulation]

Note: this procedure is considered Not Medically Necessary for all indications

 

 

HCPCS

 

C1767

Generator; neurostimulator (implantable), nonrechargeable

C1820

Generator; neurostimulator (implantable), non high-frequency with rechargeable battery and charging system

C1822

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

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, non-rechargeable, includes extension

 

 

ICD-10 Procedure

 

00HU0MZ-00HU4MZ

Insertion of neurostimulator lead into spinal canal [by approach; includes codes 00HU0MZ, 00HU3MZ, 00HU4MZ]

00HV0MZ-00HV4MZ

Insertion of neurostimulator lead into spinal cord [by approach; includes codes 00HV0MZ, 00HV3MZ, 00HV4MZ]

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

Spinal cord stimulation consists of an implantable medical device used to treat chronic pain. A surgical procedure is required and is conducted in two phases. The first phase involves placing electrodes in the epidural space of the spinal column. The electrode is connected to a surgically implanted pulse generator. A low voltage current is directly delivered to specific areas of the spinal cord via the implanted electrodes. The exact mechanism of pain relief is unknown, but it is believed that electrical signals to the spinal cord inhibit pain signals before they reach the brain. A successful temporary trial of spinal cord stimulation, which is typically performed in the outpatient setting, is required before permanent implantation of the device to increase the long-term success of the procedure. The second phase involves permanent electrodes which are usually implanted only after a trial of therapy (via electrodes temporarily implanted in the epidural space) demonstrates at least a 50% improvement in chronic pain. Several spinal cord stimulator devices have United States Food and Drug Administration approval and clearance for marketing.

This therapy is reserved for pain that has failed to respond to less invasive conventional measures and should remain a last resort treatment. Spinal cord stimulation is especially helpful in chronic refractory pain that is neuropathic in nature (that is, due to damage of peripheral nerves). This includes conditions such as failed back syndrome, reflex sympathetic dystrophy, arachnoiditis, radiculopathies, phantom limb pain, or peripheral neuropathy. Spinal cord stimulation is less effective in treating nociceptive pain (from nerve irritation as opposed to damage) or central deafferentation pain from stroke or a spinal cord injury. Spinal cord stimulation has also been investigated in severe limb ischemia. Results to date are equivocal and additional research data is being accumulated.

Another technique for treating chronic pain is the use of subcutaneous target stimulation (also referred to as peripheral subcutaneous field stimulation). This method involves the use of electrodes implanted directly at the painful area in the subcutaneous space, bypassing the spinal column and nerves. The electrodes are attached to a pulse generator which delivers permanent electrical stimulation. Like the implanted spinal cord stimulators, subcutaneous target stimulators are done in a two-phase process. The first phase involves a temporary trial with the second phase as a permanent implantation following at least a 50% reduction in pain following the temporary trial.

Battery life for spinal cord stimulators can vary depending on the power settings. Most non-rechargeable implanted batteries can last 5-7 years while rechargeable batteries can last up to 10 years.

Implanted Epidural Spinal Cord Stimulators
Chronic Pain
Evaluation of treatments of pain ideally requires randomized, placebo-controlled trials in order to control for the anticipated placebo effect. However, placebo-controlled trials of spinal cord stimulation (SCS) are problematic since individuals can sense the stimulation. Therefore, trials have focused on individuals randomized to SCS or continued medical management. Kumar and colleagues (2007) reported the 6-month results of the Prospective Randomised Controlled Multicentre Trial of the Effectiveness of Spinal Cord Stimulation (PROCESS), an international multi-center randomized comparison of SCS plus conventional medical management (CMM) versus CMM alone in 100 individuals with moderate to severe chronic radicular pain after at least one operation for a herniated disc. At 6 months, 48% of the SCS group achieved the primary outcome of 50% improvement in leg pain, but only 9% of the CMM group achieved this outcome. Furthermore, the SCS group had better 6-month back pain, physical functioning, and other quality of life outcomes. These favorable outcomes were maintained at 2 years (Kumar, 2008). In a trial of 54 individuals with chronic reflex sympathetic dystrophy (that is, complex regional pain syndrome), Kemler and colleagues (2000) reported there was a statistically significant improvement in pain in the 36 individuals randomized to the SCS arm compared to 18 randomized to physical therapy. However, pain reduction in the SCS group was no longer statistically significant at the 4- and 5-year follow-up (Kemler, 2006). A small randomized study of spinal cord stimulation in 27 individuals with chronic back and extremity pain reported successful management of pain in 55% of individuals at 6-month follow up (North, 1994). In 1996, Burchiel published the results of a randomized controlled trial of 70 individuals followed for 1 year. A significantly greater proportion of individuals initially randomized to repeat lumbosacral surgery opted to cross over to the spinal cord stimulation arm of the trial, compared to those initially in the spinal cord stimulation arm of the trial crossing over to lumbosacral surgery (Burchiel, 1996).

Although the lack of a placebo control and long-term follow-up limit the interpretation of results, the consistent report of pain relief at short to mid-term follow-up is a significant outcome in these individuals who are refractory to medical management.

Taylor (2006) conducted a systematic review and meta-analysis of spinal cord stimulation. The analysis included multiple case series in addition to the randomized studies, reviewed above. This review supported the use of SCS in individuals with refractory neuropathic back and leg pain/failed back syndrome and chronic regional pain syndrome type I/type II. It concluded that SCS not only reduces pain, but also improves quality of life, reduces analgesic consumption, and allows some individuals to return to work, with minimal significant adverse events, and may also result in significant cost savings over time.

A clinical trial is underway to compare the effectiveness of SCS plus optimal medical management to optimal medical management alone in individuals with failed back surgery syndrome (Rigoard, 2013). This is a multi-center, open-label, randomized, parallel-group study. The participants are to be assessed at baseline, randomized 1:1 to either the SCS group plus optimal medical management or optimal medical management alone. The participants will be assessed at 6 months to see what the proportion is for a greater than 50% reduction in low back pain. Recruitment began in 2013 and is still ongoing.

In a 2016 systematic review of literature by Grider and colleagues, six randomized controlled trials were reviewed for the use of spinal cord stimulation in chronic spinal pain with assessment of effectiveness. For the included studies, the primary outcome parameter was pain relief with a secondary outcome of functional improvement. Studies were included if they had at least 20 participants with a follow-up of at least 12 months. Of the six studies included in the analysis, three assessed efficacy and all three reported short-term and long-term relief. Using Cochrane review criteria and Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB), the authors concluded that there is Level I to II evidence to support the efficacy of spinal cord stimulation in chronic spinal pain.

Depression, anxiety and poor pain coping can lead to diminished effectiveness of spinal cord stimulation. A 2015 study by Block and colleagues reported on how pre-implant psychological functioning using the Minnesota Multiphasic Personality Inventory–2–Restructured Form (MMPI-2-RF) affects spinal cord stimulator outcomes. A total of 319 participants completed the MMPI-2-RF pre-implant. About half of the participants completed the MMPI-2-RF again post-implant. At about five months post-implant, the authors found that many of the scales that reflected emotional dysfunction and somatic/cognitive dysfunction were found to have poorer spinal cord stimulator outcomes. This study does have some limitations including only half of the initial participants completed the follow-up survey, the reliance on self-reporting to assess outcomes, and a five-month follow-up post implant.

Critical Limb Ischemia
Critical limb ischemia is described as pain at rest or the presence of ischemic limb lesions. If an individual is not a suitable candidate for limb revascularization (typically due to insufficient distal runoff), it is estimated that amputation will be required in 60%–80% of these individuals within a year. Spinal cord stimulation has been investigated for the management of ischemic pain and prevention of amputation in individuals with critical limb ischemia. It has been presumed that change of sympathetic tone and an increase of nutritional blood flow allows for clinical improvement of the ischemia thereby relieving pain and decreasing the incidence of amputation. Klomp and colleagues (1999) conducted a study that randomized 120 individuals with critical limb ischemia not suitable for vascular reconstruction to best medical care with or without spinal cord stimulation. The primary endpoint was limb survival at 2 years. Amputation-free survival was not improved nor was the risk of major amputation significantly reduced. Both groups also reported similar levels of pain reduction. In both groups, the rates of amputation were highest within the first 3 months of the study, reflecting the limitations with both treatment options.

In 2009, Klomp and colleagues analyzed evidence about SCS in individuals with critical limb ischemia. The authors concluded that SCS is no more effective in preventing amputations than standard medical treatment (e.g., analgesics, wound care or antibiotics if necessary). In summary, there appear to be questionable benefits from SCS related to limb salvage at 12 months but benefits have not been demonstrated at 18 to 24 months. There do not appear to be other benefits in terms of ulcer healing, quality of life or improved limb oxygenation. Thus, the evidence for a significant health outcome benefit from SCS for critical limb ischemia is insufficient to draw firm conclusions at this time.

A Cochrane review on SCS for non-reconstructable chronic critical leg ischemia included six European studies (five of which were randomized controlled trials [RCT]) with 444 individuals (Ubbink, 2005, 2013). None of the studies were blinded due to the nature of the treatment. At the 12-month follow-up, limb salvage improved by 11% compared with any form of conservative treatment. The SCS individuals required significantly less analgesics. However, there was no difference in ulcer healing, quality of life measures, or transcutaneous pO2 measurements. No single RCT demonstrated a significant benefit to SCS for limb salvage. The overall risk of complications or additional SCS treatment was 17%. The report concluded that there is evidence to favor SCS over standard conservative treatment to improve salvage and clinical situation in individuals with critical leg ischemia and that, “The benefits of SCS against the possible harm of relatively mild complications and costs must be considered.” This review has been criticized for including a non randomized study in which individuals were treated with SCS based on transcutaneous pO2 measurements (Klomp, 2006). More than 30% of the “control” group underwent amputation within 2 weeks representing an “intense selection bias” according to Klomp. Klomp’s analysis of the five RCTs did not show a significant reduction in amputation risk at 18 months. Responding to Klomp’s criticisms, the Cochrane reviewers acknowledge the magnitude of the beneficial effects from SCS may appear to be small.

Thalamic Pain
Lopez, et al (2009) published results of a retrospective analysis of 8 cases of individuals suffering from intractable pain of established or suspected thalamic origin. These individuals were treated with SCS in the cervical or dorsal cord. No participant was suffering pain from a complete hemibody or facial area. The cause of pain in 5 cases was stroke (plus 1 suspected). Multiple sclerosis was responsible for pain in 2 cases. An upper or lower extremity was affected in 6 cases. Extension to adjacent trunk was common. Exclusive trunk pain was treated in 2 cases. The follow-up period was 36-149 months. Two participants were not battery-implanted because pain relief was insufficient during the trial phase. Two participants had a further stroke: One died and one was cured from pain. Good-to-excellent results were attained in 6 participants; long-term good-to-excellent results were maintained in 3 participants. The authors concluded that, despite previous adverse reports, certain cases of thalamic pain can be effectively alleviated through SCS.

Katayama, et al (2001) reported on the effects of SCS, deep brain stimulation (DBS) of the thalamic nucleus ventralis caudalis (VC) and motor cortex stimulation (MCS) in 45 individuals with post-stroke pain. Satisfactory pain control was obtained more frequently as the stimulation site was moved to higher levels (7% by SCS, 25% by DBS and 48% by MCS). A painful sensation was sometimes produced by stimulation of the VC as well as the post-central, pre-central and pre-frontal cortices. Such a sensation occurred less frequently as the stimulation site was moved to higher levels (50% at the VC, 39% at the post-central cortex, 6% at the pre-central cortex and 3% at the pre-frontal cortex). The authors concluded that the abnormal processing of nociceptive information develops at the level of deafferentation and spreads to higher levels to a varying extent. This may be one of the reasons why satisfactory pain control was obtained more frequently as the stimulation site was moved to higher levels.

Treatment of thalamic pain remains challenging. The role of SCS in management of thalamic pain continues to be studied. Further evaluation with appropriately controlled comparative clinical trials is needed to fully evaluate the potential benefits of SCS in thalamic pain.

Implantable Subcutaneous Target Stimulation
A new peripheral neurostimulation technique has been proposed for the treatment of certain chronic pain conditions. Subcutaneous target stimulation delivers electrical stimulation at the site of maximum pain via electrodes implanted subcutaneously. A retrospective review by Sator-Katzenschlager (2010) reports the findings of 119 individuals who received subcutaneous target stimulation for chronic pain. Participating individuals had already failed systemic or less invasive treatments and were not deemed to be candidates for further surgery. A trial period of subcutaneous target stimulation was attempted for 1 to 2 weeks. Individuals kept a pain diary during the trial period and those who reported at least a 50% reduction in pain were eligible for the permanent implant. A total of 111 participants were eligible for, and received, the permanent implant. Pain intensity was measured using a self-reported 11-point (0-10) numerical rating scale. Prior to implantation, the overall mean pain intensity score was 8.2. After implantation, the overall mean pain intensity score was 4.0. Pain intensity decreased in 101 of the participants and remained unchanged in 9 of the participants. Participants were followed for 3 months. Complications included infection of the lead or neurostimulator (n=7), lead dislocation (n=14), and lead fracture (n=6). And while the subcutaneous target stimulation approach for the management of chronic pain appears to be promising, further prospective long-term evaluation is required.

Burgher and colleagues (2011) reported on a retrospective review of 10 individuals who underwent a trial of subcutaneous stimulation for neck and back pain. All participating individuals had prior failed conservative treatment and those who had prior spine surgery were deemed to not be candidates for any further surgery. Six of the 10 had at least a 50% reduction in pain and were offered permanent implant. Follow-up ranged from 2-9 months. All 6 participants who received the permanent implant reported pain relief. There was one reported complication of a lead migration. There are clear limitations of this report; it is retrospective, has a small group size and lacks a control group.

Subcutaneous target stimulation appears to be a promising alternative to implanted spinal cord stimulators for the treatment of chronic pain, however current literature is limited to small group sizes, case series, and retrospective reviews. Further long-term follow-up evaluations and controlled trials are necessary to determine safety and efficacy.

Definitions

Central deafferentation pain: Refers to pain related to central nervous system damage from stroke or spinal cord injury.

Critical limb ischemia: Pain at rest or the presence of ischemic limb lesions.

Dorsal column: A portion of the spinal cord, traversing its entire length, which carries sensory information (including pain), to the brain.

Ischemia: The lack of blood flow to any organ. If pronounced the organ becomes deficient in oxygen and injury or death of the organ may then result. Ischemic syndromes are often manifested by significant pain on an intermittent or chronic basis.

Neuropathic pain: Refers to pain resulting from actual damage to the peripheral nerves.

Nociceptive pain: Refers to pain resulting from irritation rather than damage to the nerves.

Subcutaneous: The area directly under the skin.

References

Peer Reviewed Publications:

  1. Block AR, Marek RJ, Ben-Porath YS, Kukal D. Associations Between Pre-Implant Psychosocial Factors and Spinal Cord Stimulation Outcome: Evaluation Using the MMPI-2-RF. Assessment. 2015 Aug 28.
  2. Burchiel KJ, Anderson VC, Brown FD, et al. Prospective, multicenter study of spinal cord stimulation for relief of chronic back and extremity pain. Spine. 1996; 21(23):2786-2794.
  3. Burgher AH, Huntoon MA, Turley TW, et al. Subcutaneous peripheral nerve stimulation with inter-lead stimulation for axial neck and low back pain: case series and review of the literature. Neuromodulation. 2012; 15(2):100-107.
  4. Cameron T. Safety and efficacy of spinal cord stimulation for the treatment of chronic pain: a 20 year literature review. J Neurosurg. 2004; 100 (3 Suppl Spine):254-267.
  5. de Jongste MJ, Hautvast RW, Hillege HL, Lie KI. Efficacy of spinal cord stimulation as adjunctive therapy for intractable angina pectoris: a prospective, randomized clinical study. Working Group on Neurocardiology. J Am Coll Cardiol. 1994; 23(7):1592-1597.
  6. Diedrichs H, Zobel C, Theissen P, et al. Symptomatic relief precedes improvement of myocardial blood flow in patients under spinal cord stimulation. Curr Control Trials Cardiovasc Med. 2005; 6(1):7.
  7. Di Pede F, Lanza GA, Zuin G, et al. Immediate and long-term clinical outcome after spinal cord stimulation for refractory stable angina pectoris. Am J Cardiol. 2003; 91(8):951-955.
  8. Ekre O, Norrsell H, Wahrborg P, et al. Temporary cessation of spinal cord stimulation in angina pectoris-effects on symptoms and evaluation of long-term effect determinants. Coron Artery Dis. 2003; 14(4):323-327.
  9. Gowda RM, Khan IA, Punukollu G, et al. Treatment of refractory angina pectoris. Int J Cardiol. 2005; 101(1):1-7.
  10. Grider JS, Manchikanti L, Carayannopoulos A, et al. Effectiveness of spinal cord stimulation in chronic spinal pain: A systematic review. Pain Physician. 2016; 19(1):E33-E54.
  11. Hautvast RW, de Jongste MJ, Staal MJ, et al. Spinal cord stimulation in chronic intractable angina pectoris: A randomized, controlled efficacy study. Am Heart J. 1998; 136(6):1114-1120.
  12. Katayama Y, Yamamoto T, Kobayashi K, et al. Motor cortex stimulation for post-stroke pain: comparison of spinal cord and thalamic stimulation. Stereotact Funct Neurosurg. 2001; 77(1-4):183-186.
  13. Kemler MA, Barendse GA, van Kleef M, et al. Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy. N Engl J Med. 2000; 343(9):618-624.
  14. Kemler MA, de Vet HC, Barendse GA, et al. Spinal cord stimulation for chronic reflex sympathetic dystrophy--five-year follow-up. N Engl J Med. 2006; 354(22):2394-2396.
  15. Klomp HM, Spincemaille GH, Steyerberg EW, et al. Spinal cord stimulation in critical limb ischemia: a randomized trial. Lancet.1999; 353(9158):1040-1044.
  16. Klomp HM, Steyerberg EW, Habbema JD, van Urk H.; ESES Study Group. What is the evidence on efficacy of spinal cord stimulation in (subgroups of) patients with critical limb ischemia? Ann Vasc Surg. 2009; 23(3):355-363.
  17. Klomp HM, Steyerberg EW, van Urk H, Habbema JD.; ESES Study Group. Spinal cord stimulation is not cost-effective for non-surgical management of critical limb ischaemia. Eur J Vasc Endovasc Surg. 2006; 31(5):500-508.
  18. Kumar K, Taylor RS, Jacques L, et al. Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomised controlled trial in patients with failed back surgery syndrome. Pain. 2007; 132(1-2):179-188.
  19. Kumar K, Taylor RS, Jacques L, et al. The effects of spinal cord stimulation in neuropathic pain are sustained: a 24-month follow-up of the prospective randomized controlled multicenter trial of the effectiveness of spinal cord stimulation. Neurosurgery. 2008; 63(4):762-770.
  20. Lopez JA, Torres LM, Gala F, Iglesias I. Spinal cord stimulation and thalamic pain: long-term results of eight cases. Neuromodulation. 2009; 12(3):240-243.
  21. Mannheimer C, Eliasson T, Andersson B, et al. Effects of spinal cord stimulation in angina pectoris induced by pacing and possible mechanisms of action. BMJ. 1993; 307(6092):477-480.
  22. Mannheimer C, Eliasson T, Augustinsson LE, et al. Electrical stimulation versus coronary artery bypass surgery in severe angina pectoris: the ESBY study. Circulation 1998; 97(12):1157-1163.
  23. Meglio M. Spinal cord stimulation in chronic pain management. Neurosurg Clin N Am. 2004; 15(3):297-306.
  24. North RB, Kidd DH, Lee MS, Plantodosi S. A prospective, randomized study of spinal cord stimulation versus reoperation for failed back surgery syndrome: initial results. Stereotact Funct Neurosurg. 1994; 62(1-4):267-272.
  25. Rigoard P, Desai MJ, North RB, et al. Spinal cord stimulation for predominant low back pain in failed back surgery syndrome: study protocol for an international multicenter randomized controlled trial (PROMISE study). Trials. 2013; 14:376.
  26. Sanderson JE, Ibrahim B, Waterhouse D, Palmer RB. Spinal electrical stimulation for intractable angina -long-term clinical outcome and safety. Eur Heart J. 1994; 15(6):810-814.
  27. Sator-Katzenschlager S, Fiala K, Kress HG, et al. Subcutaneous target stimulation (STS) in chronic noncancer pain: a nationwide retrospective study. Pain Pract. 2010; 10(4):279-286.
  28. Taylor RS. Spinal cord stimulation in complex regional pain syndrome and refractory neuropathic back and leg pain/failed back surgery syndrome: results of a systematic review and meta-analysis. J Pain Symptom Manage. 2006; 31(4 Suppl):S13-19.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Society of Anesthesiologists, Inc. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists task force on chronic pain management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010; 112(4):810-833.
  2. Centers for Medicare and Medicaid Services. National Coverage Determination: Electrical Nerve Stimulators. NCD #160.7. Effective August 7, 1995. Available at: http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed on October 20, 2017.
  3. Manchikanti L, Boswell M, Singh V, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2009; 12(4):699-802.
  4. National Institute for Health and Clinical Excellence. Technology appraisal 159. Spinal cord stimulation for chronic pain of neuropathic or ischaemic origin. October 2008. Available at: https://www.nice.org.uk/guidance/TA159/chapter/1-guidance. Accessed on October 20, 2017.
  5. Ubbink DT, Vermeulen H. Spinal cord stimulation for non-reconstructable chronic critical leg ischaemia. Cochrane Database Syst Rev. 2005;(3):CD004001; 2013;(2):CD004001.
Index

 

Critical Limb Ischemia

Implantable Neurostimulator

Neuropathic Pain

Peripheral Subcutaneous Field Stimulation

Spinal Cord Stimulation

Subcutaneous Target Stimulation

 

History

Status

Date

Action

New

11/02/2017

Medical Policy & Technology Assessment Committee (MPTAC) review. Moved content of SURG.00060 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS) to new clinical utilization management guideline document with the same title. Updated Coding section to remove 0282T-0285T deleted 12/31/2016.