Coverage of electrical nerve stimulation is limited to those stimulators and situations defined below when used to alleviate chronic intractable pain, unless otherwise stated.

CENTRAL NERVOUS SYSTEM

1. Dorsal Column Stimulator (63650, 63655, 63685)

   This includes the surgical implantation of neurostimulator electrodes within the dura mater (via laminectomy) or the percutaneous insertion of electrodes in the epidural space often referred to as the PICES (Percutaneous implantation of spinal column electrical stimulator) system.

2. Depth Brain Neurostimulation (64999)

   This is the stereotactic implantation of electrodes in the deep brain (e.g., thalamus and periaqueductal gray matter).

   Deep brain stimulation (DBS) via an implanted deep brain stimulator for the control of tremors consists of an electrode implanted into the thalamus, and connected by lead wire under the skin to a pulse generator implanted in the chest. When activated, the device sends a constant stream of tiny electrical pulses to the brain, blocking tremors. To turn the stimulator on or off, the patient touches a handheld magnet over the pulse generator.

   DBS is eligible to control tremors due to essential tremor (333.1) or Parkinson's Disease (332.0), when medication has failed.

   The DBS should be a last resort when all other treatments, including medications, have failed to control the tremors. Further, the patient should receive medical and neurophysiological monitoring before and after the implantation. Payment will be allowed only for DBS using a stimulator implanted on one side of the brain (unilaterally); bilateral DBS is investigational, and, therefore, is not covered and is billable by the participating/preferred provider.
   

1. Transcutaneous Electrical Nerve Stimulation (TENS) (64550)

   This is a non-invasive technique where the stimulator is attached to the surface of the skin over the peripheral nerve to be stimulated.

2. Percutaneous Electrical Nerve Stimulation (PENS) (64555)

   This procedure involves stimulation of the peripheral nerves by a needle electrode inserted through the skin.

   Both the TENS and the PENS are reimbursed when employed to assess a patient's suitability for continued treatment with an electrical nerve stimulator.

   Generally, a physician or physical therapist should be able to determine within a trial period of two months whether the patient is likely to derive a significant therapeutic benefit from the continued use of electrical stimulation. Once this is determined, the patient should employ the TENS at home, or if PENS was used, a stimulator should be implanted. Consequently, continued treatments (64550), rather than assessment services, furnished by a physician in his office, by a physical therapist (applicable to TENS only) or out-patient clinic should be denied.

   Claims for the TENS or PENS assessment services should be reported under code 95999 with payment equated to the level of reimbursement for an intermediate office visit.

   Usually, the physician or physical therapist providing the assessment TENS service will provide the necessary equipment. If the patient rents the stimulator from a supplier during the trial period, payment may be made for the rental of the unit as well as the physician's or physical therapist's service, when a benefit. However, the combined payment may not exceed the amount which would have been payable to the physician or physical therapist alone for the total assessment service.

   If the services continue for longer than two months, the claim should be evaluated to determine if the patient's condition is chronic, in which case the TENS would be covered as a prosthetic device.

3. Implanted Peripheral Nerve Stimulator (64575, 64590)

   This procedure involves the implantation of electrodes around a selected peripheral nerve. 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 which is connected to an antenna which is attached to the skin surface over the receiver unit. Sciatic and ulnar nerves are often the sites of such an implant.

4. Implanted Autonomic Nerve Stimulator (64577)

   This procedure is eligible only for the implantation of a phrenic nerve stimulator for treatment of patients with partial or complete respiratory insufficiency. Implantation of an autonomic nerve stimulator other than phrenic is not eligible for payment. In addition, treatment for conditions other than partial or complete respiratory insufficiency is considered investigational.

   See MPB O-9 for information on the phrenic nerve stimulator device.

5. Vagus Nerve Stimulator (61885, 61886, 64573)

   The implantation of a vagus nerve stimulator consists of a generator which is implanted under the collar bone and connected by wire to the vagus nerve in the neck, where it delivers electrical signals to the brain to control seizures. It includes an external programming system which is used by the physician to change stimulation settings. Patients can turn the stimulator on and off with a hand-held magnet by holding it over the stimulator.

   The implantation of a vagus nerve stimulator for seizure control is eligible only when used as a last resort for adults and adolescents (12 years of age and older), with epilepsy with partial onset seizures (345.4-345.51). Additionally, eligibility is limited to those cases where the seizures cannot be controlled by any other method, i.e., surgery or medication.

   Routine adjustments or maintenance of a nerve stimulator (95970-95975) following implantation and performed during the normal postoperative period are considered part of the global surgical service. No additional allowance should be made for this service unless the adjustments are required because of complications or they are performed after the normal postoperative period.

   Claims for the removal of an implanted stimulator should be reported under the appropriate code (63660, 63688, 64585, 64595, 64999). If a second stimulator is implanted (e.g., because of infection or malfunction), payment should be made only for the reimplantation under the appropriate implantation code. No
   additional allowance should be made for the removal of the first unit.

   Use of electrical nerve stimulators and related services other than those listed above, or for conditions other than those listed above (e.g., multiple sclerosis, muscular dystrophy, or other motor function disorders), is investigational, and therefore, not eligible for payment unless otherwise stated.
   

TENS is considered eligible for coverage for treatment of acute postoperative pain and for treatment of severe and chronic pain. For chronic pain, TENS has an assessment period of one (1) week. For acute postoperative pain, rental of the stimulator should be limited to seven (7) days. Anything in excess of seven (7) days should be given individual consideration.

PRN References

02/1997, TENS, coverage for
02/1997, PENS, coverage for
02/1998, Deep brain stimulation, coverage for

Long-term transcutaneous electrical nerve stimulation (TENS) use: impact on medication utilization and physical therapy costs, Clin J Pain, Vol. 14, Issue 1, 03/1998

Deep brain stimulation for movement disorders, Neurosurg Clin N Am, Vol. 9, Issue 2, 04/1998

Diaphragm pacing, Chest Surg Clin N Am, Vol. 8, Issue 2, 05/1998

Vagus nerve stimulation therapy for partial-onset seizures, A randomized active-control trial, Neurology, Vol. 51, July 1998

Unilateral thalamic deep brain stimulation for refractory essential tremor and Parkinson's disease tremor, Neurology, Vol. 51, Issue 4, 10/1998

Percutaneous electrical nerve stimulation (PENS): a complementary therapy for the management of pain secondary to bony metastasis, Clin J Pain, Vol. 14, Issue 4, 12/1998

Vagus Nerve Stimulation, Epilepsia, Vol. 39, No. 7, 1998

Percutaneous Electrical Nerve Stimulation for Low Back Pain, A Randomized Crossover study, Journal of the American Medical Association, Vol. 281, No. 9, 03/1999

The effects of epimysial electrode location on phrenic nerve recruitment and the relation between tidal volume and interpulse interval, IEEE Trans Rehabil Eng, Vol. 7, Issue 2, 06/1999

Treatment of neuropathic pain in a patient with diabetic neuropathy using transcutaneous electrical nerve stimulation applied to the skin of the lumbar region, Physical Therapy, Vol. 79, Issue 8, 08/1999

Neuropsychological and quality of life outcome after thalamic stimulation for essential tremor, Neurology, Vol. 53, Issue 8, 11/1999

Percutaneous electrical nerve stimulation: an alternative to TENS in the management of sciatica, Pain, Vol. 83, Issue 2, 11/1999

Use of transcutaneous electrical nerve stimulation in a young child with pain from open perineal lesions, J Pain Symptom Manage, Vol. 18, Issue 5, 11/1999