Description
Dorsal Column (Spinal cord) stimulation involves surgical implantation of neurostimulator electrodes within the dura mater (endodural) or percutaneous insertion of electrodes in the epidural space. The implantation consists of two stages: the first stage contains an implantation of neurostimulator electrode(s) and a connection of an external neurostimulator. In some cases, temporary electrodes are used. It is a short trial to assess the patient’s suitability for ongoing treatment with a permanent surgically implanted nerve stimulator. If pain relief is achieved, the temporary system may be transitioned to a permanent system. The second stage involves subcutaneous insertion of a permanent neurostimulator with connection of the implanted electrode(s). Spinal cord neurostimulators (SCS) may be covered as therapies for the relief of chronic intractable pain, and medical records will be reviewed to determine if the implantation of SCS meets Medicare coverage criteria and documentation requirements.
Approved Code(s)
63685
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefit
3. 42 CFR §405.929 – Post-payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. 42 CFR §424.5- Basic Conditions, (a)(6)- Sufficient Information
8. 42 CFR §411.15- Particular Services Excluded from Coverage, (k)- Any Services Not Reasonable and Necessary
9. Medicare National Coverage Determination Manual, Chapter 1, Part 2, §160.2 Treatment of Motor Function Disorders with Electric Nerve Stimulation and §160.7 Electrical Nerve Stimulators, (B) Central Nervous System Stimulators (Dorsal Column and Depth Brain Stimulators)
10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
11. Medicare Program Integrity Manual, Chapter 13 – Local Coverage Determinations, §13.5.4 Reasonable and Necessary Provision in LCDs
12. First Coast Local Coverage Determination L36035- Spinal Cord Stimulation for Chronic Pain; Effective 10/01/2015; Revised 11/28/2019
13. First Coast Local Coverage Article A57709- Billing and Coding: Spinal Cord Stimulation for Chronic Pain; Effective 10/03/2018
14. Novitas Local Coverage Determination L35450- Spinal Cord Stimulation (Dorsal Column Stimulation); Effective 10/01/2015; Revised 09/26/2019
15. Novitas Local Coverage Article A57023- Billing and Coding: Spinal Cord Stimulation (Dorsal Column Stimulation); Effective 09/26/2019; Revised 09/26/2019
16. Palmetto Local Coverage Determination L37632- Spinal Cord Stimulators for Chronic Pain; Effective 01/29/2018; Revised 05/13/21
17. Palmetto Local Coverage Article A56876- Billing and Coding: Spinal Cord Stimulators for Chronic Pain; Effective 08/22/2019; Revised 05/13/21
18. Noridian Local Coverage Determination L36204- Spinal Cord Stimulators for Chronic Pain; Effective 06/01/2016; Revised 12/01/2019
19. Noridian Local Coverage Determination L35136 – Spinal Cord Stimulators for Chronic Pain; Effective 10/01/2015; Revised 12/01/2019
20. Noridian Local Coverage Article A57791 – Billing and Coding: Spinal Cord Stimulators for Chronic Pain; Effective 12/01/2019, Revised 01/01/2022
21. Noridian Local Coverage Article A57792 – Billing and Coding: Spinal Cord Stimulation for Chronic Pain; Effective 12/01/19, Revised 01/01/2022
22. American Hospital Association (AHA) Coding Clinic for HCPCS
23. American Medical Association (AMA) Current Procedure Terminology Assistant
24. National Correct Coding Initiative Policy Manual for Medicare Services, Chapter VIII – Surgery: Endocrine, Nervous, Eye and Ocular Adnexa, and Auditory Systems, CPT Codes 60000 – 69999
25. American Medical Association (AMA) Current Procedural Terminology (CPT) Manual