UnitedHealthcare ® Medicare Advantage
Policy Guideline
ELECTRICAL NERVE STIMULATORS (NCD 160.7)
Guideline Number: MPG086.02
Table of Contents
Page
INSTRUC TIONS FOR USE ............................................1
POLIC Y SUMMARY......................................................1
APPLIC ABLE C ODES ...................................................2
REFERENC ES.............................................................3
GUIDELINE HISTORY/REVISION INFORMATION ............4
Approval Date: August 10, 2016
Related Medicare Advantage Policy Guidelines

Assessing Patient's Suitability for Electrical Nerve
Stimulation Therapy (NC D 160.7.1)

C ategory III C PT C odes
Related Medicare Advantage C overage Summary

Stimulators - Electrical and Spinal C ord Stimulators
INSTRUC TIONS FOR USE
This Policy Guideline is applicable to UnitedHealthcare Medicare Advantage Plans offered by Unite dHealthcare and its
affiliates for health care services submitted on C MS 1500 forms and, when specified, to those billed on UB04 forms
(C MS 1450), or their electronic comparative. The information presented in this Policy Guideline is believed to be
accurate and current as of the date of publication.
This Policy Guideline provides assistance in administering health benefits. All reviewers must first identify member
eligibility, any federal or state regulatory requirements, C enters for Medicare and Medicaid Services (C MS) policy, the
member specific benefit plan coverage, and individual provider contracts prior to use of this Policy Guideline. When
deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific
benefit plan document may differ greatly from the standard benefit plan up on which this Policy Guideline is based. In
the event of a conflict, the member specific benefit plan document supersedes this Policy Guideline. Other Policies and
Guidelines may apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Policies and Guidelines
as necessary.
UnitedHealthcare follows Medicare coverage guidelines and regularly updates its Medicare Advantage Policy Guidelines
to comply with changes in C MS policy. UnitedHealthcare encourages physicians and other healthc are professionals to
keep current with any C MS policy changes and/or billing requirements by referring to the C MS or your local carrier
website regularly. Physicians and other healthcare professionals can sign up for regular distributions for policy or
regulatory changes directly from C MS and/or your local carrier. This Policy Guideline is provided for informational
purposes. It does not constitute medical advice.
POLIC Y SUMMARY
Overview
Two general classifications of electrical nerve stimulators are employed to treat chronic intractable pain: peripheral
nerve stimulators and central nervous system stimulators.
Implanted Peripheral Nerve Stimulators
Payment may be made under the prosthetic device benefit for implanted peripheral nerve stimulators. Use of this
stimulator involves 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 connected to an antenna unit which is attached to the skin surface over
the receiver unit. Implantation of electrodes requires surgery and usually necessitates an operating room.
Note: Peripheral nerve stimulators may also be employed to assess a patient's suitability for continued treatment with
an electric nerve stimulator. As explained in §160.7.1, such use of the stimulator is covered as part of the total
diagnostic service furnished to the beneficiary rather than as a prosthesis.
Central Nervous System Stimulators (Dorsal Column and Depth Brain Stimulators)
The implantation of central nervous system stimulators may be covered as therapies for the relief of chronic
intractable pain, subject to the following conditions:
Ele ctrical Ne rve Stimulators (NCD 160.7)
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There are two types of implantations covered by this instruction:

Dorsal Column (Spinal Cord) Neurostimulation: The surgical implantation of neurostimulator electrodes
within the dura mater (endodural) or the percutaneous insertion of electrodes in the epidural space is covered.

Depth Brain Neurostimulation: The stereotactic implantation of electrodes in the deep brain (e.g., thalamus
and periaqueductal gray matter) is covered.
Conditions for Coverage
No payment may be made for the implantation of dorsal column or de pth brain stimulators or services and supplies
related to such implantation, unless all of the conditions listed below 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;
With respect to other treatment modalities (pharmacological, surgical, physical or psychological therapies) they
have been tried and did not prove satisfactory and are judged to be 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 the facilities, equipment, professional and support personnel required for the proper diagnosis, treatment
training and followup of the patient must be available; and
Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation.
APPLIC ABLE C ODES
The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in
this guideline does not imply that the service described by the code is a covered or non -covered health service.
Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws
that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or
guarantee claim payment. Other Policies and Guidelines may apply .
C PT C ode
0282T
Description
Percutaneous or open implantation of neurostimulator electrode array(s),
subcutaneous (peripheral subcutaneous field stimulation), including imaging
guidance, when performed, cervical, thoracic or lumbar; for trial, including removal
at the conclusion of trial period
0283T
Percutaneous or open implantation of neurostimulator electrode array(s),
subcutaneous (peripheral subcutaneous field stimulation), including imaging
guidance, when performed, cervical, thoracic or lumbar; permanent, with
implantation of a pulse generator
0284T
Revision or removal of pulse generator or electrodes, including imaging guidance,
when performed, including addition of new electrodes, when performed
63650
Percutaneous implantation of neurostimulator electrode a rray, epidural
63655
Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural
63661
Removal of spinal neurostimulator electrode percutaneous array(s), including
fluoroscopy, when performed
63662
Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy
or laminectomy, including fluoroscopy, when performed
63663
Revision including replacement, when performed, of spinal neurostimulator electrode
percutaneous array(s), including fluoroscopy, when performed
63664
Revision including replacement, when performed, of spinal neurostimulator electrode
plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when
performed
63685
Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct
or inductive coupling
63688
Revision or removal of implanted spinal neurostimulator pulse generator or receiver
64553
Percutaneous implantation of neurostimulator electrode array; cranial nerve
64555
Percutaneous implantation of neurostimulator electrode array; peripheral nerve
(excludes sacral nerve)
CPT® is a registered trademark of the American Medical Association
Ele ctrical Ne rve Stimulators (NCD 160.7)
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ICD-10 Diagnosis Codes
See related Local C overage Determinations
REFERENC ES
CMS National Coverage Determinations (NCDs)
NC D 160.7 Electrical Nerve Stimulators
Reference NC D: NC D 160.7.1 Assessing Patient's Suitability for Electrical Nerve Stimulation Therapy
CMS Local Coverage Determinations (LCDs)
LC D
L33392 (C ategory lll C PT C odes) NGS
L33777 (Non-covered Services) First
C oast
Medicare Part A
C T, MA, ME, NH, NY, RI, VT
FL, PR, VI
Medicare Part B
C T, MA, ME, NH, NY, RI, VT
FL, PR, VI
L34328 (Peripheral Nerve and
Peripheral Nerve Field Stimulation)
Noridian
AS, C A, GU, HI, MP, NV
L34556 (Spinal cord Stimulators for
C hronic Pain) Palmetto
NC , SC , VA, WV
L35094 (Services That Are Not
Reasonable and Necessary) Novitas
AR, C O, DE, DC , LA, MD, MS, NJ,
NM, OK, PA, TX
AR, C O, DE, DC , LA, MD, MS, NJ, NM,
OK, PA, TX
L35136 (Spinal C ord Stimulators for
C hronic Pain) Noridian
AS, C A, GU, HI, MP, NV
AS, C A, GU, HI, MP, NV
L35450 (Spinal C ord Stimulation
(Dorsal C olumn Stimulation) Novitas
AR, C O, DC , DE, LA, MD, MS, NJ,
NM, OK, PA, TX
AR, C O, DC , DE, LA, MD, MS, NJ, NM,
OK, PA, TX
L36035 (Spinal C ord Stimulation for
C hronic Pain) First C oast
FL, PR, VI
FL, PR, VI
L36204 (Spinal C ord Stimulators for
C hronic Pain) Noridian
AK, AZ, ID, MT, ND, OR, SD, UT,
WA, WY
AK, AZ, ID, MT, ND, OR, SD, UT, WA,
WY
AK, AZ, ID, MT, ND, OR, SD, UT, WA,
WY
L24473 (Non-C overed Services)
Noridian Retired 09/30/2015
L25275 (C ategory III C PT C odes)
NGS Retired 09/30/2015
C T, IL, MA, ME, MN, NH, NY, RI, VT,
WI
L27445 (Non-covered Services)
Noridian Retired 09/30/2015
AK, AZ, ID, MT, ND, OR, SD, UT,
WA, WY
L28991 (Non-covered Services) First
C oast Retired 09/30/2015
FL
L29023 (Non-covered Services) First
C oast Retired 09/30/2015
PR, VI
C T, IL, MA, ME, MN, NH, NY, RI, VT,
WI
L29288 (Non-covered Services) First
C oast Retired 09/30/2015
FL
L29398 (Non-covered Services) First
C oast Retired 09/30/2015
PR, VI
L31686 (Services That Are Not
Reasonable and Necessary) Novitas
Retired 09/30/2015
AR, C O, DC , DE, LA, MD, MS, NJ,
NM, OK, PA, TX
AR, C O, DC , DE, LA, MD, MS, NJ, NM,
OK, PA, TX
L31711 (Non-C overed C ategory III
C PT C odes) Palmetto
Retired 09/30/2015
NC , SC , VA, WV
L32549 (Spinal C ord Stimulators for
C hronic Pain) Palmetto
Retired 09/30/2015
NC , SC , VA, WV
L33489 (Spinal C ord Stimulators for
C hronic Pain) Noridian
Retired 09/30/2015
AS, C A, GU, HI, MP, NV
Ele ctrical Ne rve Stimulators (NCD 160.7)
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LC D
L33714 (Peripheral Nerve and
Peripheral Nerve Field Stimulation)
Noridian Retired 09/30/2015
Medicare Part A
Medicare Part B
AS, C A, GU, HI, MP, NV
L34705 (Spinal C ord Stimulation
(Dorsal C olumn Stimulation)) Novitas
Retired 09/30/2015
AR, C O, DC , DE, LA, MD, MS, NJ,
NM, OK, PA, TX
AR, C O, DC , DE, LA, MD, MS, NJ, NM,
OK, PA, TX
L35648 (Spinal C ord Stimulation for
C hronic Pain) First C oast
Retired 09/30/2015
FL, PR, VI
FL, PR, VI
CMS Articles
Article
A54675 (Non-covered Services
C oding Guidelines) First C oast
Medicare Part A
Medicare Part B
FL, PR, VI
FL, PR, VI
A54817 (Spinal C ord Stimulation for
C hronic Pain - code guide) First
C oast
FL, PR, VI
FL, PR, VI
A52082 (C PT C ategory III Non
C overed and C overed C odes R3)
Noridian Retired 09/30/2015
AK, AZ, ID, MT, ND, OR, SD, UT, WA,
WY
A52083 (C PT C ategory III Non
C overed and C overed C odes R3)
Noridian Retired 09/30/2015
AK, AZ, ID, MT, ND, OR, SD, UT, WA,
WY
CMS Benefit Policy Manual
C hapter 15; § 120 Prosthetic Devices
UnitedHealthcare Commercial Policies
Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
Implanted Electrical Stimulator for Spinal C ord
Others
Jurisdiction 11 Part B Assigned IC D-9-C M C odes for National C overage Determinations, Palmetto Website
GUIDELINE HISTORY/REVISION INFORMATION
Date
08/10/2016
Action/Description

Annual review
Ele ctrical Ne rve Stimulators (NCD 160.7)
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