RETIRED Local Coverage Determination (LCD)

Spinal Cord Stimulation (Dorsal Column Stimulation)

L35450

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.
Retired

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L35450
Original ICD-9 LCD ID
Not Applicable
LCD Title
Spinal Cord Stimulation (Dorsal Column Stimulation)
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 09/26/2019
Revision Ending Date
07/13/2023
Retirement Date
07/13/2023
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Spinal Cord Stimulation (Dorsal Column Stimulation). Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Spinal Cord Stimulation (Dorsal Column Stimulation) and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:

IOM Citations

  • CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, Section 160.7 Electrical Nerve Stimulators.
  • CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in LCDs.


Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claims that lacks the necessary information to process the claim.
  • Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
  • Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

 

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

History/Background and/or General Information

Spinal cord stimulation blocks pain conduction pathways to the brain and may stimulate endorphins. The neurostimulator electrodes used for this purpose are implanted percutaneously in the epidural space through a special needle. Some patients may need an open procedure requiring laminectomy to place the electrodes.

After placement of the electrodes, the patient is provided with an external neurostimulator, initially on a trial basis. The trial period may be extended up to four weeks. If during the trial period it is determined that the modality is not effective, or it is not acceptable to the patient, the electrodes may be removed.

If the trial has been successful, a spinal neurostimulator and pulse generator are inserted subcutaneously and connected to the implanted electrodes. In some cases, the trial may be conducted using temporary electrodes.

Covered Indications

Dorsal column stimulators may be covered as therapies for the relief of chronic intractable pain under the following circumstances:

  1. To treat chronic pain caused by lumbosacral arachnoiditis that has not responded to medical management including physical therapy. (Presence of arachnoiditis is usually documented by presence of high levels of proteins in the Cerebrospinal Fluid [CSF] and/or by myelography or Magnetic Resonance Imaging [MRI]).
  2. To treat intractable pain caused by nerve root injuries, post-surgical or post-traumatic including that of post-laminectomy syndrome (failed back syndrome).
  3. To treat intractable pain caused by complex regional pain syndrome I & II.
  4. To treat intractable pain caused by phantom limb syndrome that has not responded to medical management.
  5. To treat intractable pain caused by end-stage peripheral vascular disease, when the patient cannot undergo revascularization or when revascularization has failed to relieve painful symptoms and the pain has not responded to medical management.
  6. To treat intractable pain caused by post-herpetic neuralgia.
  7. To treat intractable pain caused by plexopathy.
  8. To treat intractable pain caused by intercostal neuralgia that did not respond to medical management and nerve blocks.
  9. To treat intractable pain caused by cauda equina injury.
  10. To treat intractable pain caused by incomplete spinal cord injury.


Limitations

No payment may be made for the implantation of dorsal column stimulators or services and supplies related to such implantation, unless all of the “conditions for coverage” located in NCD 160.7 for Electrical Nerve Stimulators have been met.

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Refer to the Local Coverage Article: Billing and Coding: Spinal Cord Stimulation (Dorsal Column Stimulation), A57023, for all coding information.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The medical record documentation must support the medical necessity of the services as stated in this policy.
  4. When revision including replacement of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy or revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy are performed, documentation must include the date the initial insertion was performed.

Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Generally, the physician should be able to determine whether the patient is likely to derive a significant therapeutic benefit from continuing use of an implanted nerve stimulator within a trial period of four weeks. In a few cases, this determination may take longer to make. Documentation of the medical necessity for such diagnostic services furnished beyond four weeks must be provided upon request for redetermination.

Generally, electronic analysis services are not considered medically necessary when provided at a frequency more often than once every 30 days. More frequent analysis may be necessary in the first month after implantation.

Sources of Information

Contractor is not responsible for the continued viability of websites listed.

L32753, Spinal Cord Stimulation (Dorsal Column Stimulation), Novitas Solutions Jurisdiction H Local Coverage Determination

Other Contractor Policies

Contractor Medical Directors

Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
07/13/2023 R10

This LCD is being retired effective for dates of service on and after 07/13/2023.

  • LCD Being Retired
09/26/2019 R9

LCD revised and published on 09/26/2019. Consistent with CMS Change Request 10901, the entire coding section has been removed from the LCD and placed into the related Billing and Coding Article, A57023. All CPT codes and coding information within the text of the LCD has been placed in the Billing and Coding Article. The T85 series of ICD-10 codes and Z45.42 have been added to the billing and coding article in response to an inquiry.

  • Other (Provider request
    )
01/01/2019 R8

LCD revised and published on 02/14/2019 effective for dates of service on and after 01/01/2019 to reflect the annual CPT/HCPCS code updates. For the following CPT/HCPCS code(s) either the short description and/or the long description has been changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: 95970, 95971, and 95972.

CMS IOM and NCD language was removed from the LCD and reference to NCD 160.7 was added to the Limitations section (reference CR 10901). Updates have been made to the references in the CMS National Coverage Policy section.

  • Revisions Due To CPT/HCPCS Code Changes
  • Other (Clarification)
11/09/2017 R7

LCD revised and published on 11/09/2017 effective for dates of service on and after 10/01/2016. Note(s) have been applied to previous versions that were in effect on 10/01/2016 and after. The following ICD-10-CM codes have been added as covered diagnoses to the Group 2 required secondary diagnosis codes: M47.21, M47.22, M47.23, M47.24, M47.25, M47.26, and M47.27. Added hyperlink to NCD 160.7 to the “Related National Coverage Documents” section.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; therefore, not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Inquiry)
10/01/2016 R6 LCD revised and published on 10/13/2016 effective for dates of service on and after 10/01/2015. Note(s) have been applied to previous versions that were effective on 10/01/2015 and after. The 7th digit character D and S has been added to all of the S diagnosis codes listed in group 2.
  • Other (Inquiry )
10/01/2016 R5 LCD revised and published on 09/29/2016 effective for dates of service on and after 10/01/2016 to reflect the ICD-10 Annual Code Updates. The following ICD-10 code has been deleted and therefore removed from the LCD In Group 2: M50.12. The following codes have been deleted from the ICD-10 That DO NOT Support Medical Necessity grouping: F32.8 and F34.8. The following ICD-10 code(s) have been added to Group 2: G56.43, G56.83, G56.93, G57.73, G57.83, G57.93, M50.121, M50.122 and M50.123. The following codes have been added to the ICD-10 codes that DO NOT Support Medical Necessity grouping: F32.89, F34.81 and F34.89.
  • Revisions Due To ICD-10-CM Code Changes
01/01/2016 R4 LCD revised and published on 01/28/2016 effective for dates of service on and after 01/01/2016 to reflect the annual CPT/HCPCS code updates. CPT/HCPCS code 95973 has been deleted and therefore removed from the LCD. The short description or the long description was changed for CPT code 95972. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R3 LCD revised and published 01/23/2015 to correct the publication date of the annual CPT/HCPCS code updates incorrectly listed as 01/22/2015 in revision history below. The code updates remain as listed in the revision history below.
  • Revisions Due To CPT/HCPCS Code Changes
  • Typographical Error
10/01/2015 R2 LCD revised and published on 01/22/2015 effective for dates of service on and after 10/01/2015 to reflect the annual CPT/HCPCS code updates. Either the short description and/or the long description was changed for CPT/HCPCS code 95972. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R1 LCD revised and published on 10/09/2014 to remove the CPT/HCPCS code L8680 consistent with CR8645 effective for dates of service on or after 10/01/2015.
  • Revisions Due To CPT/HCPCS Code Changes
N/A

Associated Documents

Attachments
N/A
Related National Coverage Documents
NCDs
160.7 - Electrical Nerve Stimulators
Public Versions
Updated On Effective Dates Status
07/13/2023 09/26/2019 - 07/13/2023 Retired You are here
09/20/2019 09/26/2019 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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