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) Page 1 of 4 Unite dHealthcare Medicare Advantage Policy Guideline Approve d 08/10/2016 Proprietary Information of UnitedHealthcare. Copyright 2016 United HealthCare Services, Inc. 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) Page 2 of 4 Unite dHealthcare Medicare Advantage Policy Guideline Approve d 08/10/2016 Proprietary Information of UnitedHealthcare. Copyright 2016 United HealthCare Services, Inc. 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) Page 3 of 4 Unite dHealthcare Medicare Advantage Policy Guideline Approve d 08/10/2016 Proprietary Information of UnitedHealthcare. Copyright 2016 United HealthCare Services, Inc. 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) Page 4 of 4 Unite dHealthcare Medicare Advantage Policy Guideline Approve d 08/10/2016 Proprietary Information of UnitedHealthcare. Copyright 2016 United HealthCare Services, Inc.