Implanted Electrical Stimulator for Spinal Cord

CLINICAL POLICY
IMPLANTED ELECTRICAL STIMULATOR FOR
SPINAL CORD
Policy Number: PAIN 022.3 T2
Effective Date: July 1, 2014
Table of Contents
Page
CONDITIONS OF COVERAGE...................................
COVERAGE RATIONALE………………………………..
U.S. FOOD AND DRUG ADMINISTRATION...............
APPLICABLE CODES.................................................
REFERENCES............................................................
POLICY HISTORY/REVISION INFORMATION............
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Policy History Revision Information
Related Policies:
• Bariatric Surgery
• Electrical Stimulation
for the Treatment of
Pain and Muscle
Rehabilitation
• Gastrointestinal
Motility Disorders
• Occipital Neuralgia
and Cervicogenic,
Cluster and Migraine
Headache
The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's
contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage
enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written
notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term
Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.
Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the
Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are
any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any
policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of
Coverage will govern.
CONDITIONS OF COVERAGE
Applicable Lines of Business/Products
Benefit Type
Referral Required
This policy applies to Oxford Commercial plan
membership
General Benefits Package
No
(Does not apply to non-gatekeeper products)
Yes
Authorization Required
(Precertification always required for inpatient admission)
Precertification with Medical Director
Review Required
Applicable Site(s) of Service
No
Inpatient, Outpatient
(If site of service is not listed, Medical Director review is
required)
COVERAGE RATIONALE
For information regarding medical necessity review, when applicable, see MCG™ Care
Guidelines, 18th edition, 2014, MCG: Implanted Electrical Stimulator, Spinal Cord
ACG: A-0243 (AC).
Implanted Electrical Stimulator for Spinal Cord: Clinical Policy (Effective 07/01/2014)
©1996-2014, Oxford Health Plans, LLC
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U.S. FOOD AND DRUG ADMINISTRATION (FDA)
Spinal Cord Stimulators (SCS) devices are approved for use “as an aid in the management of
chronic intractable pain of the trunk and/or limbs, including unilateral or bilateral pain associated
with the following: failed back surgery syndrome, intractable low back pain and leg pain” (FDA,
2004). They are not specifically approved for the treatment of chronic stable angina. Totally
implantable SCS systems are regulated by the FDA as Class III premarket-approval (PMA)
devices. Examples of these devices include the PRECISION™ Plus SCS (Spinal Cord
Stimulator) System (Boston Scientific, MA) and the Genesis™ IPG System (St. Jude Medical, Inc.
previously Advanced Neuromodulation Systems, Inc.; Plano, TX). Systems with external
transmitters (e.g., X-trel® Neurostimulation Systems [Medtronic, Inc., Minneapolis MN]) are
regulated by the FDA as Class II 510(k)
Additional information (product code LGW) is available at:
http://www.accessdata.fda.gov/scripts/cdrh/devicesatfda/index.cfm. Accessed March 18, 2014.
APPLICABLE CODES
The codes listed in this policy are for reference purposes only. Listing of a service or device code
in this policy does not imply that the service described by this code is a covered or non-covered
health service. Coverage is determined by the Member’s plan of benefits or Certificate of
Coverage. This list of codes may not be all inclusive.
CPT®/HCPCS Code
0282T
0283T
0284T
0285T
63650
63655
63685
L8680
L8681
L8682
L8685
L8686
L8687
L8688
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
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
Revision or removal of pulse generator or electrodes, including
imaging guidance, when performed, including addition of new
electrodes, when performed
Electronic analysis of implanted peripheral subcutaneous field
stimulation pulse generator, with reprogramming when performed
Percutaneous implantation of neurostimulator electrode array, epidural
Laminectomy for implantation of neurostimulator electrodes,
plate/paddle, epidural
Insertion or replacement of spinal neurostimulator pulse generator or
receiver, direct or inductive coupling
Implantable neurostimulator electrode, each
Patient programmer (external) for use with implantable programmable
neurostimulator pulse generator, replacement only
Implantable neurostimulator radiofrequency receiver
Implantable neurostimulator pulse generator, single array,
rechargeable, includes extension
Implantable neurostimulator pulse generator, single array,
nonrechargeable, includes extension
Implantable neurostimulator pulse generator, dual array,
rechargeable, includes extension
Implantable neurostimulator pulse generator, dual array,
nonrechargeable, includes extension
®
CPT is a registered trademark of the American Medical Association.
Implanted Electrical Stimulator for Spinal Cord: Clinical Policy (Effective 07/01/2014)
©1996-2014, Oxford Health Plans, LLC
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REFERENCES
The foregoing Oxford policy has been adapted from an existing UnitedHealthcare national policy
that was researched, developed and approved by UnitedHealthcare Medical Technology
Assessment Committee. [2014T0567C]
POLICY HISTORY/REVISION INFORMATION
Date
•
07/01/2014
•
Action/Description
Updated list of applicable CPT/HCPCS codes; added 0282T,
0283T, 0284T, 0285T, L8680, L8681, L8682, L8685, L8686,
L8687 and L8688
Archived previous policy version PAIN 022.2 T2
Implanted Electrical Stimulator for Spinal Cord: Clinical Policy (Effective 07/01/2014)
©1996-2014, Oxford Health Plans, LLC
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