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Section: Miscellaneous
Number: Z-7
Topic: Electrical Nerve Stimulation
Effective Date: September 26, 2011
Issued Date: September 26, 2011
Date Last Reviewed:

General Policy Guidelines

Indications and Limitations of Coverage

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

Use of electrical nerve stimulators and related services other than those specifically addressed within this policy, e.g., percutaneous neuromodulation therapy (PNT), or for conditions other than those addressed within this policy (e.g., multiple sclerosis, muscular dystrophy, or other motor function disorders), is considered experimental/investigational. It is not eligible for reimbursement. The medical efficacy for alternate use of electrical nerve stimulation has not been established. A participating, preferred, or network provider can bill the member for the denied service.

CENTRAL NERVOUS SYSTEM

Dorsal Column Stimulation (63650, 63655, 63685)
Dorsal column stimulation, (spinal cord stimulation) is eligible for the relief of chronic intractable neurogenic pain of the trunk and/or limbs when all of the following conditions have been met:

  • There is documented pathology, or an objective basis for the pain; and
  • Dorsal column stimulation is being used as a late or last resort when other treatment modalities (pharmacological, surgical, physical, or psychological therapies) have been tried and did not prove satisfactory, cannot be tolerated, or are contraindicated; and
  • A minimum 3 day trial of percutaneous spinal stimulation has resulted in a significant pain reduction of 50% or more; and
  • There is no evidence of existing untreated drug addiction (per American Society of Addiction Medicine [ASAM] guidelines); and
  • The patient has undergone careful physical and psychological evaluations prior to implantation; and
  • The patient has been evaluated by a pain management specialist prior to implantation; and
  • All the facilities, equipment, and professional and support personnel required for the proper diagnosis, treatment training, and follow-up of the patient must be available.

The use of spinal cord stimulation for conditions other than chronic intractable neurogenic pain of the trunk and/or limbs, (for example, chronic stable refractory angina or peripheral ischemia) is considered experimental or investigational and is not eligible for payment. The medical effectiveness of such therapy has not been established. A participating, preferred, or network provider can bill the member for the denied service.

Date Last Reviewed - 09/2009

Deep Brain Neurostimulation (61863, 61864, 61867, 61868, 61885, 61886)
Unilateral or bilateral deep brain stimulation (DBS) of the thalamic ventralis intermedius nucleus (VIM) is considered eligible for the treatment of intractable tremors due to essential tremor or Parkinson's disease (PD), when all of the following criteria are met:

  • Diagnosis of essential tremor or idiopathic Parkinson's disease (with the presence of at least two cardinal PD features - tremor, rigidity, bradykinesia) that is not responding satisfactorily to drug therapy; and
  • Marked disabling tremor of at least 3 or 4 on the Fahn-Tolosa-Marin Clinical Tremor Rating Scale (or equivalent scale), causing significant limitation in activities of daily living; and
  • No diagnosed dementia, severe depression, cerebral atrophy, or Hoehn and Yahr stage V Parkinson's disease; and
  • No focal lesion of the basal ganglia (e.g., a space occupying lesion or lacunae) at the target site that would negate the result of thalamic stimulation; and 
  • Sufficient residual motor function in the upper extremity so that it is reasonable to expect an improvement following the surgery; and
  • Willingness and ability of the patient to cooperate during a conscious operative procedure, as well as during post-surgical evaluations, adjustments of medications and stimulator settings.

Unilateral or bilateral deep brain stimulation of the subthalamic nucleus (STN) or globus pallidus interna (GPi) for the treatment of Parkinson's disease is considered eligible when all of the following criteria are met:

  • Diagnosis of advanced idiopathic Parkinson's disease as determined by the Hoehn and Yahr stage or a minimal score of 30 points on the Unified Parkinson's Disease Rating Scale (UPDRS) part III motor subscale when off medication for 12 hours; and
  • Parkinson's disease (with the presence of at least two cardinal PD features - tremor, rigidity, bradykinesia) that is not responding satisfactorily to drug therapy; and
  • Presence of disabling Parkinson's disease symptoms or medication side effects (e.g., dyskinesias, motor fluctuations, or disabling "off" periods), despite optimal medical therapy; and
  • No diagnosed dementia, severe depression, cerebral atrophy, or Hoehn and Yahr stage V Parkinson's disease; and
  • Parkinson's disease is Levodopa responsive with clearly defined "on" periods; and
  • Willingness and ability to cooperate during conscious operative procedure, as well as during post-surgical evaluations, adjustments of medications and stimulator settings.

Deep brain stimulation is eligible when it is used as a treatment for chronic intractable (drug refractory) primary dystonia, including generalized and/or segmental dystonia, hemidystonia, and cervical dystonia (torticollis) in patients seven years of age or above.

Deep brain stimulation is considered experimental/investigational and is non-covered when used in the following situations:

  • When used for other movement disorders, including but not limited to multiple sclerosis, post-traumatic dyskinesia, and tardive dyskinesia;
  • When used for treatment of tremor from other causes such as trauma, degenerative disorders, metabolic disorders, or infectious diseases;
  • When used for other indications, including cluster headaches, refractory depression, obsessive/compulsive disorder, and Tourette's syndrome.

A participating, preferred, or network provider can bill the member for the non-covered service.

Date Last Reviewed - 05/2010

PERIPHERAL NERVOUS SYSTEM

Transcutaneous Electrical Nerve Stimulation (TENS)(64550)
Percutaneous Electrical Nerve Stimulation (PENS)(64555)
Transcutaneous Electrical Nerve Stimulation (TENS) is not an eligible service under the UCR and Fee Schedule programs except as identified in the benefits schedule.

When a covered benefit, both TENS and PENS are considered eligible when used for the treatment of chronic intractable pain and as a means of assessing the need for continued treatment with an implanted electrical nerve stimulator. The use of PENS and TENS for conditions other than chronic intractable pain or for treatment of acute pain (i.e., acute post-operative pain) is considered experimental/investigational and is not eligible for payment. A participating, preferred, or network provider may bill the member for the denied service.

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 use the TENS at home, or if PENS was used, a stimulator should be implanted. Consequently, continued treatments, rather than assessment services, furnished by a physician in his office, by a physical therapist (applicable to TENS only) or outpatient 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 TENS assessment 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.

Date Last Reviewed - 09/2009

Implanted Peripheral Nerve Stimulation (64575, 64590)
Implanted peripheral nerve stimulation is eligible when used to alleviate chronic intractable neurogenic pain when all of the following criteria are met:

  • The chronic intractable neurogenic pain is refractory to other methods of treatment (e.g., analgesics, physical therapy, local injection, surgery), and
  • There is objective evidence of nerve injury or disease pathology (e.g., electromyography), and
  • There is no psychological contraindication to peripheral nerve stimulation, and
  • There is no addiction to drugs (per American Society of Addiction Medicine [ASAM[ guidelines), and
  • A trial of transcutaneous stimulation was successful (resulting in at least a 50% reduction in pain).

The use of peripheral nerve stimulation for post-herpetic neuralgia and for all other indications is considered experimental or investigational. A participating, preferred, or network provider can bill the member for the denied service.

Date Last Reviewed - 09/2009

Phrenic Nerve Stimulation (64560, 64577)
The percutaneous (64560) or open (via incisions) (64577) implantation of a phrenic nerve stimulator is intended to be an alternative option in the management of patients with chronic respiratory insufficiency who are dependent upon a mechanical ventilator.

Phrenic nerve stimulator implantation is eligible:

  • for treatment of chronic ventilator or respiratory insufficiency requiring mechanical ventilation due to either:
    • lesions/injury of the spinal cord at or above the C-3 vertebral level, or
    • central alveolar hypoventilation, either primary or secondary to a brain stem disorder
  • the phrenic nerve is viable and intact, and
  • diaphragmatic function is sufficient to accommodate chronic stimulation.

The use of phrenic nerve stimulation for the treatment of other conditions or for other indications is considered experimental/investigational and is not eligible for reimbursement. A participating, preferred, or network provider can bill the member for the denied service.

Date Last Reviewed - 08/2009

See Medical Policy Bulletin O-9 for information on the phrenic nerve stimulator device.

Vagus Nerve Stimulation (61885, 61886, 64553, 64568, 64569, 64570)
The implantation of a vagus nerve stimulator for seizure control is eligible only when used as a last resort for patients with epilepsy with partial onset seizures. Eligibility is limited to those cases where the seizures cannot be controlled by any other method, i.e., surgery or medication.

The use of vagus nerve stimulation for treatment of refractory depression is considered experimental/investigational. It is not eligible for payment. Scientific evidence has not demonstrated the long-term clinical efficacy of VNS and its impact on treatment-resistant depression. A participating, preferred, or network provider can bill the member for the denied service.

Date Last Reviewed - 06/2010

Implanted Neuromuscular Neurostimulator (64565, 64580)
The percutaneous (64565) or open (via incision)(64580) implantation of neuromuscular neurostimulator electrodes for chronic pain relief is considered experimental/investigational, and is therefore, non-covered. The clinical value of intramuscular stimulation for pain relief has not been validated by randomized controlled studies. A participating, preferred, or network provider can bill the member for the non-covered service.

Date Last Reviewed - 10/2010

Occipital Nerve Stimulation (ONS)(61885, 61886, 64553, 64568, 64569, 64570, 64999)

Occipital nerve stimulation (ONS) is considered experimental/investigational for all indications, and therefore, is non-covered. Randomized controlled trials (to account for potential placebo effect) with greater numbers of patients and longer follow-up are needed. In addition, no implanted occipital nerve stimulators have received U.S. Food and Drug Administration (FDA) approval. A participating, preferred, or network provider can bill the member for the non-covered service.

Routine adjustments or maintenance of a nerve stimulator other than a deep brain stimulator, (95970-95975, 95978, 95979) 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 performed after the normal postoperative period. Adjustments required because of complications are eligible.

Intensive electronic analysis and programming of a deep brain stimulator, may be necessary immediately following implantation to achieve optimal stimulus parameters. Recognizing these needs, six (6) such programming visits will be covered within 60 days of the surgical implantation of the deep brain stimulator, and once every 30 days thereafter, as necessary.

Claims for the removal of an implanted stimulator should be reported under the appropriate code (63661, 63662, 63663, 63664, 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.

Nerve stimulators are not covered except under those groups that provide coverage for durable medical equipment (e.g., TENS stimulators - E0720 and E0730) and prosthetic devices (implanted stimulators).

See Medical Policy Bulletin S-131 for guidelines on sacral nerve stimulation.

See Medical Policy Bulletin Y-16 for guidelines on electrical stimulation for wound healing.

See Medical Policy Bulletin E-45 for guidelines on interferential stimulators.

See Medical Policy Bulletin E-40 for guidelines on Neuromuscular Electrical Stimulation (NMES) Device Used by Spinal Cord Injured Patients for Walking.

Description

CENTRAL NERVOUS SYSTEM

Dorsal Column Stimulation
Dorsal column stimulation involves 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. Low voltage electrical signals are delivered to the spinal cord in order to override or mask sensations of pain.

Deep Brain Neurostimulation
Deep brain stimulation (DBS) involves the stereotactic implantation of electrodes in the deep brain (e.g., thalamus and periaqueductal gray matter).

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

PERIPHERAL NERVOUS SYSTEM

Transcutaneous Electrical Nerve Stimulation (TENS)
TENS is a non-invasive technique where the stimulator is attached to the surface of the skin over the peripheral nerve to be stimulated. The electrical stimulation is produced by an electrical pulse generator which delivers current that can be varied in form, intensity and frequency to the superficial electrodes, decreasing the patient's perception of pain.

Percutaneous Electrical Nerve Stimulation (PENS)
PENS involves the use of fine needle electrodes which are inserted through the skin to stimulate peripheral sensory nerves. The electrical stimulation is produced by a battery-operated electrical pulse generator which delivers current that can be varied in form, intensity, and frequency to decrease the patient's perception of pain.

Implanted Peripheral Nerve Stimulation
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.

Phrenic Nerve Stimulation
Phrenic nerve stimulation is a type of autonomic nerve stimulation which provides electrical stimulation of the patient's phrenic nerve to contract the diaphragm rhythmically and produce breathing in patients who have hypoventilation. The goal of phrenic pacing is to provide adequate ventilatory support, maximum mobility and quality of life. The pacer system consists of an implanted generator, electrodes, leads and an external antenna and transmitter.

Vagus Nerve Stimulation
Vagus nerve stimulation involves the implantation of a generator under the collar bone. The generator is connected by wire to the vagus nerve in the neck, where it delivers electrical signals to the brain to control seizures. An external programming system 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.

Occipital Nerve Stimulation
Occipital nerve stimulation (ONS) delivers a small electrical charge to the occipital nerve in an attempt to prevent migraines and other headaches in patients who have not responded to medications. The device consists of a subcutaneously implanted pulse generator (in the chest wall or abdomen) attached to extension leads that are tunneled to join electrodes placed across one or both occipital nerves at the base of the skull. Continuous or intermittent stimulation may be used.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

618636186461867618686188561886
636506365563661636626366363664
636856368864550645536455564560
645656456864569645706457564577
645806458564590645956499995970
959719597295973959749597595978
95979E0720E0730L8680L8681L8682
L8683L8685L8686L8687L8688L8689

Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the Federal Employee Program.

Comprehensive / Wraparound / PPO / Major Medical Guidelines

Refer to General Policy Guidelines

Any reference in this bulletin to non-billable services by a network provider may not be applicable to Major Medical.

Managed Care (HMO/POS) Guidelines

Refer to General Policy Guidelines

Publications

PRN

02/1997, TENS, coverage for
02/1997, PENS, coverage for
02/1998, Deep brain stimulation, coverage for
04/2002, Bilateral deep brain stimulation now covered
04/2003, Age restriction for vagus nerve stimulation removed
02/2004, Deep brain stimulation eligible for treatment of dystonia
02/2004, Percutaneous neuromodulation therapy is investigational
10/2005, Deep brain stimulator programming and analysis coverage revised
08/2006, Vagus nerve stimulation for treatment of refractory depression considered investigational
12/2010, Deep brain stimulation coverage guidelines outlined
12/2010, Dorsal column stimulation eligible for chronic intractable neurogenic trunk and limb pain
12/2010, Implanted peripheral nerve stimulation covered for treating chronic intractable neurogenic pain
12/2010, Phrenic nerve stimulation coverage guidelines outlined
12/2010, Transcutaneous electrical nerve stimulation coverage guidelines explained
06/2011, Occipital nerve stimulation considered investigational

References

Dorsal Column Stimulation

Boswell MV, Trescot AM, Datta S, et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007:10(1):7-11.

Cruccu G, Aziz TZ, Garcia-Larrea L, et al. EFNS guidelines on neurostimulation therapy for neuropathic pain. Eur J Neurol. 2007; 14(9):952-70.

Kumar K, Taylor RS, Jacques L, et al. Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomized controlled trial in patients with failed back surgery syndrome. Pain. 2007;132(1-2):179-88.

Lanner G, Spendel MC. Spinal cord stimulation for the treatment of chronic non-malignant pain. Acta Neurochir Suppl. 2007;97(Pt 1):79-84.

North RB, Kidd, Shipley J, Taylor RS. Spinal cord stimulation versus reoperation for failed back surgery syndrome: a cost effectiveness and cost utility analysis based on a randomized, controlled trial. 2007;61(2):361-8.

DeVries J, DeJongste MJ, Durencamp A, et al. The sustained benefits of long-term neurostimulation in patients with refractory chest pain and normal coronary arteries. Eur J Pain. 2007;11(3):360-5.

Neurostimulation Technology for the Treatment of Chronic Pain: A Focus on Spinal Cord Stimulation, Expert Reveiw of Medical Devices, Volume 4 (2), March 2007

Chou R. Generating evidence on spinal cord stimulation for failed back surgery syndrome: not yet fully charged. Clin J Pain. 2008;24(9):757-8.

Jang HD, Kim MS, Chang CH, et al. Analysis of failed spinal cord stimulation trials in the treatment of intractable chronic pain. J Korean Neurosurg Soc. 2008;43(2):8509.

Kemler MA, de Vet HC, Barendse GA, et al. Effect 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(2):292-8.

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):762-70.

Manca A, Kumar K, Taylor RS, et al. Quality of life, resource consumption and costs of spinal cord stimulation versus conventional medical management in neuropathic pain patients with failed back surgery syndrome (PROCESS trial). Eur J Pain. 2008;4(9):472-3.

Chronic Stable Angina Pectoris

McNab D, Khan SN, Sharples LD, et al. An open-label, single-centre, randomized trial of spinal cord stimulation (SCS) vs. percutaneous myocardial laser revascularization (PMR) in patients with refractory angina pectoris: the SPiRiT trial. Eur Heart J. 2006;27(9):1048-53.

Eddicks S, Maier-Hauff K, Schenk M. Thoracic spinal cord stimulation improves functional status and relieves symptoms in patients with refractory angina pectoris: the first placebo-controlled randomized study. 2007;93(5):585-90.

Bondesson S, Pettersson T, Erdling A, et al. Comparison of patients undergoing enhanced external counterpulsation and spinal cord stimulation for refractory angina pectoris. Coron Artery Dis. 2008;19(8):627-34.

Borjesson M, Andrell P, Lundberg D, et al. Spinal cord stimulation in severe angina pectoris—a systematic review based on the Swedish Council on Technology assessment in health care report on long-standing pain. Pain. 2008;140(3):501-8.

Dyer MT, Goldsmith K, Khan S, et al. Clinical and cost-effectiveness analysis of an open label, single-centre, randomized trial of spinal cord stimulation (SCS) versus percutaneous myocardial laser revascularization (PMR) in patients with refractory angina pectoris: The SPiRiT trial. Trials. 2008;9:40.

Fricke E, Eckert S, Dongas A, et al. Myocardial sympathetic innervation in patients with symptomatic coronary artery disease: follow-up after 1 year with neurostimulation. J Nucl Med. 2008;49(9):1458-64.

Khan SN, McNabb DC, Sharples LD, et al. A study to assess changes in myocardial perfusion after treatment with spinal cord stimulation and percutaneous myocardial laser revascularization; data from a randomized trial. Trials. 2008;9:9.

Mesa JE, Yakovlev AE. Treatment of intractable angina pectoris utilizing spinal cord stimulation. Rev Cardiovasc Med. 2008;9(1):70-4.

Eckert S, Horstkotte D. Management of angina pectoris: the role of spinal cord stimulation. Am J Cardiovasc Drugs. 2009;9(1):17-28.

Fricke E, Eckert S, Dongas A, et al. Myocardial perfusion after one year of spinal cord stimulation in patients with refractory angina. Nuklearmedizin. 2009;48(3):104-109.

Taylor RS, DeVries J, Buchser E, Dejongste MJ. Spinal cord stimulation in the treatment of refractory angina: systematic review and meta-analysis of randomized controlled trials. BMC Cardiovasc Disord. 2009;9:13.

Clinical Trial NCT00121654

Clinical Trial NCT00157742

Clinical Trial NCT 00200070

Critical Limb Ischemia

Claeys LG, Berg W, Jonas S. Spinal cord stimulation in the treatment of chronic critical limb ischemia. Acta Neurochir Suppl. 2007;97(Pt 1):259-65.

Pedrini L, Magnoni F. Spinal cord stimulation for lower limb ischemic pain treatment. Interact Cardiovasc Thorac Surg. 2007 Aug;495-500.

Simpson EL, Duenas A, Holmes MW, et al. Spinal cord stimulation for chronic pain of neuropathic or ischemic origin: systematic review and economic evaluation. Health Technol Assess. 2009;13(17):1-54.

Deer TR. Spinal cord stimulation for the treatment of angina and peripheral vascular disease. Curr Pain Headache Rep. 2009;13(1):18-23. 

Klomp HM, Steyerberg EW, Habbema JD, van Urk H. What is the evidence on efficacy of spinal cord stimulation in (subgroups of) patients with critical limb ischemia? Ann Vasc Surg. 2009;23(3):355-63.

Deep Brain Stimulation

Deep Brain Stimulation for Movement Disorders, Neurosurg Clin N Am, Vol. 9, Issue 2, 04/1998

Unilateral Thalamic Deep Brain Stimulation for Refractory Essential Tremor and Parkinson's Disease Tremor, Neurology, Vol. 51, Issue 4, 10/1998

Neuropsychological and Quality of Life Outcome After Thalamic Stimulation for Essential Tremor, Neurology, Vol. 53, Issue 8, 11/1999

Appleby BS, Duggan PS, Regenberg A, et al. Psychiatric and neuropsychiatric adverse events associated with deep brain stimulation: A meta-analysis of ten years’ experience. Mov Disord. 2007; 22(12):1722-8.

Damier P, Thobois S, Witjas T, et al. Bilateral deep brain stimulation of the globus pallidus to treat tardive dyskinesia. Arch Gen Psychiatry. 2007;64(2):170-6.

Egidi M, Franzini A, Marras C et al. A survey of Italian cases of dystonia treated by deep brain stimulation. J Neurosurg Sci. 2007;51(4):153-8.

Kenney C, Simpson R, Hunter C et al. Short-term and long-term safety of deep brain stimulation in the treatment of movement disorders. J Neurosurg. 2007;106(4):621-5.

Kern DS, Kumar R.  Deep brain stimulation. Neurologist. 2007;13(5):237-52. 

Kiss ZH, Doig-Beyaert K, Eliasziw M et al. Functional and Stereotactic Section of the Canadian Neurological Society; Canadian Movement Disorders Group. The Canadian multicentre study of deep brain stimulation for cervical dystonia. Brain. 2007;130(Pt 11):2879-86.

Maciunas RJ, Maddux BN, Riley DE, et al. Prospective randomized double-blind trial of bilateral thalamic deep brain stimulation in adults with Tourette syndrome. J Neurosurg. 2007;107(5):1004-14.

Vidailhet M, Vercueil L, Houeto JL et al. Bilateral, pallidal, deep-brain stimulation in primary generalized dystonia: a prospective 3 year follow-up study.  Lancet Neurol. 2007; 6(3): 223-9.

Hauptman JS, DeSalles AA, Espinoza R, et al. Potential surgical targets for deep brain stimulation in treatment-resistant depression. Neurosurg Focus. 2008;25(1):E3

Larson PS. Deep brain stimulation for psychiatric disorders. Neurotherapeutics. 2008;5(1):50-8.

Mallet L, Polosan M, Jaafari N, et al.  Subthalamic nucleus stimulation in severe obsessive-compulsive disorder. N Engl J Med; 2008;359(20):2121-34

Mueller J, Skogseid IM, Benecke R et al.  Pallidal deep brain stimulation improves quality of life in segmental and generalized dystonia: results from a prospective, randomized sham-controlled trial. Mov Disord. 2008;23(1):131-4.

Servello D, Porta M, Sassi M, et al. Deep brain stimulation in 18 patients with severe Gelles de la Tourette syndrome (GTS) refractory to treatment: the surgery and stimulation. J Neurol Neurosurg Psychiatry. 2008;79(2):136-42.

Welter ML, Mallet L, Houeto JL, et al. Internal pallidal and thalamic stimulation in patients with Tourette syndrome. Arch Neurol. 2008;65(7):952-7.

Witt K, Daniels C, Reiff J et al. Neuropsychological and psychiatric changes after deep brain stimulation for Parkinson’s disease: a randomized, multicentre study. Lancet Neurol. 2008;7(7):605-14 (Clinical Trial NCT 00196911).

Bartsch T, Paemeleire K, Goadsby RJ. Neurostimulation approaches to primary headache disorders. Curr Opin Neurol. 2009;22(3):262-8.

Cersosimo MG, Raina GB, Benarroch EE et al. Micro lesion effect of the globus pallidus internus and outcome with deep brain stimulation in patients with Parkinson disease and dystonia. Mov Disord. 2009 [Epub ahead of print] accessed 06/02/2009.

Giacobbe P, Mayberg HS, Lozano AM. Treatment resistant depression as a failure of brain homeostatic mechanisms: Implications for deep brain stimulation. Exp Neurol. 2009 [Epub ahead of print] accessed 06/02/2009.

Hamani C, Mayberg H, Snyder B, et al.  Deep brain stimulation of the subcallosal cingulated gyrus for depression: anatomical location of active contacts in clinical responders and a suggested guideline for targeting. J Neurosurg. 2009 [Epub ahead of print] accessed 06/02/2009.

Isaias IU, Alterman RL, Tagliati M. Deep brain stimulation for primary generalized dystonia: long-term outcomes. Arch Neurol. 2009;66(4):465-70.

Weaver FM, Follett K, Stern M et al. Bilateral deep brain stimulation vs. best medical therapy for patients with advanced Parkinson disease: a randomized controlled trial. JAMA. 2009;301(1):63-73 (NCT 00056563).

Volkman J, Albanese A, Kulisevsky J et al. Long-term effects of pallidal or subthalamic deep brain stimulation on quality of life in Parkinson’s disease.  Mov Disord. 2009 [Epub ahead of print] accessed 06/02/2009.

Wang X, Chang C, Geng N, et al.  Long-term effects of bilateral deep brain stimulation of the subthalamic nucleus on depression in patients with Parkinson’s disease. Parkinsonism Relat Disord. 2009. [Epub ahead of print] accessed 06/02/2009.

Transcutaneous Electrical Nerve Stimulation (TENS)

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

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

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

Khadilkar A, Odebiyi DO, Brosseau L, et al. Transcutaneous electrical stimulation (TENS) versus placebo for chronic low back pain. Cochrane Database Syst Rev. 2008;(4)

Nnoaham KE, Kumbang J. Transcutaneous electrical nerve stimulation (TENS) for chronic pain. Cochrane Database Syst Rev. 2008;(3):CD003222.

Robb KA, Bennett MI, Johnson ME, et al. Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults. Cochrane Database Syst Rev. 2008;(3):CD006276

Sikuru L, Shmaila H, Muhammed SA. Transcutaneous electrical nerve stimulation (TENS) in the symptomatic management of chronic prostatitis/chronic pelvic pain syndrome: a placebo-controlled randomized trial. Int Braz J Urol. 2008;34(6):708-13.

Tella BA, Unubum EV, Danesi MA. The effect of TENS on selected symptoms in the management of patients with chronic tension type headache: a preliminary study. Nig Q J Hosp Med. 2008;18(1)25-9.

Cipriano G Jr., de Camargo Carvalho AC, Bernardelli GF, et al. Short-term transcutaneous electrical nerve stimulation after cardiac surgery: effect on pain, pulmonary function and electrical muscle activity. Interact Cardiovasc Thorac Surg. 2008;7(4):539-43.

DeSantana JM, Santana-Filho VJ, Guerra Dr, et al. Hypoalgesic effect of the transcutaneous electrical nerve stimulation following inguinal herniorrhaphy: a randomized, controlled trial. J Pain. 2008;9(7):623-9.

Emmiler M, Solak O, Kocogullari C, et al. Control of acute postoperative pain by transcutaneous electrical nerve stimulation after open cardiac operations: a randomized placebo-controlled prospective study. Heart Surg Forum. 2008;11(5):E300-3.

Desantana JM, Sluka KA, Lauretti GR. High and low frequency TENS reduce postoperative pain intensity after laparoscopic tubal ligation: a randomized controlled trial. Clin J Pain. 2009;25(1):12-9.

Dowswell T, Bedwell C, Lavender T, et al. Transcutaneous electrical nerve stimulation (TENS) for pain relief in labour. Cochrane Database Syst Rev. 2009;(2):CD007214.

Walsh DM, Howe TE, Johnson ME, et al. Transcutaneous electrical stimulation for acute pain. Cochrane Database Syst Rev. 2009 (2):CD006142.

Percutaneous Electrical Nerve Stimulation (PENS)

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

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

Percutaneous Electrical Nerve Stimulation: An Alternative to TENS in the Management of Sciatica, Pain, Vol. 83, Issue 2, 11/1999

Weiner DK, Perera S, Rudy TE et al., Efficacy of percutaneous electrical nerve stimulation and therapeutic exercise for older adults with chronic low back pain: a randomized controlled trial. Pain. 2008;140(2):344-57.

Implanted Peripheral Nerve Stimulation

Peripheral Nerve Stimulation for the Treatment of Chronic Pain, Journal of Clinical Neuroscience, Volume 14 (3), March 2007

Melvin EA Jr., Jordan FR, Weiner RL, Primm D. Using peripheral stimulation to reduce pain of C2-mediated occipital headaches: a preliminary report. Pain Physician. 2007;10(3):453-60.

Slavin KV. Peripheral nerve stimulation for the treatment of neuropathic craniofacial pain. Acta Neruochir Suppl. 2007;97(pt 1):115-20.

Asensio-Samper JM, Villanueva VL, Perez AV, et al. Peripheral neurostimulation in supraorbital neuralgia refractory to conventional therapy. Pain Pract. 2008;8(2):120-4.

Rauchwerger JJ, Giordano J, Rozen D, et al.  On the therapeutic viability of peripheral nerve stimulation for ilioinguinal neuralgia: Putative mechanisms and possible utility. Pain Prac. 2008;(8(2):138-143. 

Klaiput A, Kitisomprayoonkul W. Increased pinch strength in acute and subacute stroke patients after simultaneous median and ulnar sensory stimulation. Neurorehabil Neural Repair. 2009;23(4):351-6.

Kouroukli I, Neofytos D, Panaretou V, et al.  Peripheral subcutaneous stimulation for the treatment of intractable postherpetic neuralgia: two case reports and literature review. Pain Pract. 2009;9(3):225-9.

Mirone G, Natale M, Rotondo M. Peripheral median nerve stimulation for treatment of iatrogenic complex regional pain syndrome (CRPS) type II after carpal tunnel surgery. J Clin Neurosci. 2009;16(6):825-7.

Phrenic Nerve Stimulation

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

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

Onders RP, Elmo MJ, Ignagni AR. Diaphragm pacing stimulation system for tetraplegia in individuals injured during childhood or adolescence. J Spinal Cord Med. 2007;30 Suppl 1:S25-0.

Hirschfield S, Exner G, Luukkaala T, Baer GA. Mechanical ventilation or phrenic nerve stimulation for treatment of spinal cord injury-induced respiratory insufficiency. Spinal Cord. 2008;46(11):738-42.

Vagus Nerve Stimulation

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

Vagus Nerve Stimulation Therapy for Partial-Onset Seizures, A Randomized Active-Control Trial, Neurology, Vol. 51, July 1998

Fisher RS, Krauss GL, Ramsay E, et al. Reassessment: Vagus Nerve Stimulation for Epilepsy: A Report of the Therapeutics and Technology Subcommittee of the American Academy of Neurology. Neurology. 1999;53:666-669.

Vagus Nerve Stimulation for Treatment-Resistant Depression: A Randomized, Controlled Acute Phase Trial, Biological Psychiatry, Vol. 58 (5), 09/2005

Effects of 12 Months of Vagus Nerve Stimulation in Treatment-Resistant Depression: A Naturalistic Study, Biological Psychiatry, Vol. 58 (5), 09/2005

A One-Year Comparison of Vagus Nerve Stimulation with Treatment as Usual for Treatment-Resistant Depression, Biological Psychiatry, Vol. 58 (5), 09/2005

Two-Year Outcome of Vagus Nerve Stimulation (VNS) for Treatment of Major Depressive Episodes, Journal of Clinical Psychiatry, Vol. 66 (9), 09/2005

ECRI Institute. Implantable vagus nerve stimulator for treatment-resistant depression. [Emerging Technology evidence report]. Plymouth Meeting (PA): ECRI Institute; 2008 Dec 12. Available at URL address: http://www.ecri.org

Daban C, Martinez-Aran A, Cruz N, et al. Safety and efficacy of vagus nerve stimulation in treatment-resistant depression. A systematic review. J Affect Disord. 2008;110(1-2):1-15.

Dumitriu D, Collins K, Alterman R, et al. Neurostimulatory therapeutics in management of treatment-resistant depression with focus on deep brain stimulation. Mt. Sinai J Med. 2008;75(3):263-75.

Fitzgerald PB, Daskalakis ZJ. The use of repetitive transcranial magnetic stimulation and vagal nerve stimulation in the treatment of depression. 2008;21(1):25-9.

Nirenberg AA, Alpert JE, Gardner-Schulster EE, et al. Vagus nerve stimulation: 2-year outcomes for bipolar versus unipolar treatment-resistant depression. Biol Psychiatry. 2008;64(6):455-60.

Schlaepfer TE, Frick C, Zobel A, et al. Vagus nerve stimulation for depression: efficacy and safety in a European study. Psychol Med. 2008;38(5):651-61.

Yu ZJ, Weller RA, Sandidge K. Vagus Nerve Stimulation: Can it be used in adolescents or children with treatment-resistant depression? Curr Psychiatry Rep. 2008;10(2):116-22.

Preskorn SH. Treatment options for the patient who does not respond well to initial antidepressant therapy. Journal of Psychiatr Pract. 2009;15(3):202-10.

Rakofsky JJ, Holtzheimer PE, Nemeroff CB. Emerging targets for antidepressant therapies. Curr Opin Chem Biol. 2009;13(3):291-302.

Rush AJ, Seifert SE, Clinical issues in considering vagus nerve stimulation for treatment-resistant depression. Exp Neurol. 2009;219(1):36-43.

Sperling W, Reulbach U, Kornhuber J. Clinical benefits and cost effectiveness of vagus nerve stimulation in a long-term treatment of patients with major depression. Pharmacopsychiatry. 2009;42(3):85-8.

Grimm S, Bajbouj M. Efficacy of vagus nerve stimulation in the treatment of depression. Expert Rev Neurother. 2010;10(1):87-92.

Schlaepfer TE, George MS, Mayberg H. WFSB Guidelines on Brain Stimulation Treatments in Psychiatry. The world journal of biological psychiatry. 2010;11:2-18.

Shelton RC, Osuntokun O, Heinloth AN, et al. Therapeutic options for treatment-resistant depression. CNS Drugs. 2010;24(2):131-61.

Institute for Clinical Systems Improvement (ICSI). Major depression in adults in primary care. Bloomington, MN: ICSI; May 2009. Accessed 1/25/2010. Available at URL address: http://www.icsi.org/depression_5/depression_major_in_adults_in_primary_care_3.html 

California Technology Assessment Forum (CTAF). Vagus nerve stimulation for treatment resistant depression. Technology Assessment. San Francisco, CA: CTAF, February 15, 2006. Available at: http://ctaf.org/ass/viewfull.ctaf?id=65198186099. Accessed 1/25/2010.

Percutaneous Neuromodulation Therapy

White PF, Craig WF, Vakharia AS, et al. Anesth Analg. 2000;91(4):949-54.

White PF, Ghoname EA, Ahmed HE, et al. The effect of montage on the analgesic response to percutaneous neuromodulation therapy. Anesth Analg. 2001;92(2):483-7.

Borg-Stein J, Seroussi RE, Bomba L, et al. Safety and efficacy of percutaneous neuromodulation therapy in the management of subacute radiating low back pain. Pain Pract. 2003;3(2):125-34.

Rozen D, Grass GW. Intradiscal electrothermal coagulation and percutaneous neuromodulation therapy in the treatment of discogenic low back pain. Pain Pract. 2005;5(3):228-43.

Occipital Nerve Stimulation

Kapural L, Mekhail N, Hayek SM, et al. Occipital nerve electrical stimulation via the midline approach and subcutaneous surgical leads for treatment of severe occipital neuralgia: A pilot study. Anesth Analg. 2005;101(1):171-174.

Schwedt TJ, Dodick DW, Hentz J, Trentman TL, Zimmerman RS. Occipital nerve stimulation for chronic headache--long-term safety and efficacy. Cephalalgia. 2007 Feb;27(2):153-7.

Trentman TL, Dodick DW, Zimmerman RS, Birch BD. Percutaneous occipital stimulator lead tip erosion: report of 2 cases. Pain phys. 2008 Mar-Apr;11(2):253-256.

Burns B, Watkins L, Goadsby PJ. Treatment of hemicrania continua by occipital nerve stimulation with a bion device: long-term follow-up of a crossover study. Lancet Neurol. 2008 Nov;7(11):1001-12.

Burns B, Watkins L, Goadsby PJ. Treatment of intractable chronic cluster headache by occipital nerve stimulation in 14 patients. Neurology. 2009 Jan 27;72(4):341-5.

Trentman TL, Rosenfeld DM, Vargas BB, Schwedt TJ, Zimmerman RS, Dodick DW. Greater occipital nerve stimulation via the Bion microstimulator: implantation technique and stimulation parameters. Clinical trial: NCT00205894. Pain Physician. 2009 May-Jun;12(3):621-8.

Clinical Trials.gov. Accessible online at: http://clinicaltrials.gov/ct2/results?term=occipital+nerve+stimulation. Last accessed July 2011.

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Table Attachment

Text Attachment

Procedure Code Attachments

Diagnosis Codes

Covered Diagnosis Codes

Deep Brain Neurostimulation (61863, 61864, 61867, 61868, 61885, 61886)

332.0333.1333.6 

Covered Diagnosis Codes

Phrenic Nerve Stimulation (64560, 64577)

518.5518.82  

Covered Diagnosis Codes

Vagus Nerve Stimulation (61885, 61886, 64553, 64568, 64569, 64570)

345.40-345.51   

Glossary





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