1.0 CPT
PROCEDURE CODES
61000 - 61626, 61680 - 62264,
62268 - 62284, 62290 - 63048, 63050, 63051, 63055 - 64484, 64505
- 64595, 64600 - 64650, 64680 - 64999, 95961, 95962, 95970 - 95979,
95983, 95984
2.0 POLICY
2.1 Services
and supplies required in the diagnosis and treatment of illness
or injury involving the nervous system are covered.
2.2 Therapeutic
embolization (Current Procedural Terminology (CPT) procedure code
61624) may be covered for the following indications:
• Cerebral Arteriovenous
Malformations (AVMs)
• Vein of Galen Aneurysm
• Inoperable or High-Risk
Intracranial Aneurysms
• Dural Arteriovenous
Fistulas
• Meningioma
• Pulmonary Arteriovenous
Malformations (PAVMs)
The
list of indications is not all inclusive. Other indications are
covered when documented by reliable evidence as safe, effective
and comparable or superior to standard care (proven).
2.3 Implantation
of depth electrodes is covered. Implantation of a U.S. Food and
Drug Administration (FDA) approved vagus nerve stimulator, and battery
replacement, may be covered for the following indications:
2.3.1 As adjunctive
therapy in reducing the frequency of seizures in adults and adolescents
over 12 years of age, which are refractory to anti-epileptic medication.
2.3.2 As therapy
for children 12 years of age or younger who have a diagnosis of
medically refractory Lennox-Gastaut Syndrome (LGS) (a rare disease).
2.3.3 Effective
July 27, 2012, as adjunctive therapy in reducing the frequency of
seizures that are refractory to anti-epileptic medications in beneficiaries
under the age of 12.
2.4 Spinal cord and deep brain
stimulation are covered in the treatment of chronic intractable
pain. Coverage includes:
2.4.1 The accessories necessary
for the effective functioning of the covered device.
2.4.2 Repair,
adjustment, replacement and removal of the covered device and associated
surgical costs.
2.5 Endovascular coil occlusion may
be cost-shared for embolizing unruptured intracranial aneurysms
that, because of their morphology, their location, or the patient’s
general medical condition, are considered by the treating neurosurgical
team to be:
2.5.1 Very high risk for management by traditional
operative techniques; or
2.5.2 Inoperable; or
2.5.3 For embolizing
other vascular malformation such as AVMs and arteriovenous fistulae
of the neurovasculature, to include arterial and venous embolizations
in the peripheral vasculature.
2.6 FDA approved Flow Diverter
Devices (FDDs) may be cost-shared.
2.7 Thoracic epidural steroid injections for the
treatment of pain due to symptomatic thoracic disc herniations may
be considered for cost-sharing when a patient meets all of the following
criteria:
• Pain
is radicular; and
• Pain is unresponsive
to conservative treatment.
2.8 Non-pulsed Radiofrequency (RF) denervation
(CPT procedure codes 64633 - 64636) for the treatment of chronic
cervical and lumbar facet pain is covered when the following criteria
are met:
2.8.1 No prior spinal fusion surgery
in the vertebral level being treated; and
2.8.2 Low back (lumbosacral) or neck (cervical) pain,
suggestive of facet joint origin as evidenced by absence of nerve
root compression as documented in the medical record on history,
physical and radiographic evaluations; and the pain is not radicular;
and
2.8.3 Pain has failed to respond
to three months of conservative management which may consist of
therapies such as nonsteroidal anti-inflammatory medications, acetaminophen,
manipulation, physical therapy, and a home exercise program; and
2.8.4 A trial of controlled diagnostic medial branch
blocks under fluoroscopic guidance has resulted in at least a 50%
reduction in pain; and
2.8.5 If there has been a prior successful RF denervation,
a minimum time of six months has elapsed since prior RF treatment
(per side, per anatomical level of the spine).
2.9 Endoscopic laminotomy (CPT procedure code 63030)
is covered for the treatment of lumbar spinal stenosis. The endoscopic
spinal system used in the procedure must be FDA approved.
2.10 Sacral Nerve Stimulation (SNS) for the treatment
of chronic fecal incontinence is covered for patients who have failed
or are not candidates for more conservative treatment, and who have
a weak but structurally intact anal sphincter refractory to conservative
measures. See
Section 14.1 for coverage policy for the urinary
system and the Sacral Nerve Root Stimulation (SNS).
2.11 Intracranial angioplasty (CPT procedure code
61630) may be covered when medically necessary and appropriate.
2.12 Deep Brain Stimulation (DBS) for the treatment
of Parkinson’s Disease (PD) and Essential Tremor (ET) is proven
when using an FDA approved device, according to FDA indications.
2.13 Cervical laminoplasty (CPT procedure codes
63050 and 63051) may be covered when medically necessary and appropriate.
3.0 EXCLUSIONS
3.1 N-butyl-2-cyanoacrylate
(Histacryl Bleu®), iodinated poppy seed oils (e.g., Ethiodol®),
and absorbable gelatin sponges are not FDA approved.
3.2 Transcutaneous,
percutaneous, functional dorsal column electrical stimulation in
the treatment of multiple sclerosis or other motor function disorders
is unproven.
3.3 Deep brain neurostimulation in the treatment
of insomnia, depression, anxiety, and substance abuse is unproven.
3.4 Psychosurgery
is not in accordance with accepted professional medical standards
and is not covered.
3.5 Dorsal Root Entry Zone (DREZ) thermocoagulation
or microcoagulation neurosurgical procedure is unproven.
3.6 Extraoperative electrocortiography for stimulation
and recording in order to determine electrical thresholds of neurons
as an indicator of seizure focus is unproven.
3.7 Neuromuscular Electrical Stimulation (NMES)
for the treatment of denervated muscles is unproven.
3.8 Stereotactic cingulotomy is unproven.
3.9 Transcatheter placement of intravascular stent(s)
intracranial (e.g., atherosclerotic or venous sinus stenosis) including
angioplasty, if performed (CPT procedure code 61635) is unproven.
See
Chapter 1, Section 3.1 for coverage policy
regarding treatment of pseudotumor cerebri.
3.10 Balloon dilation of intracranial vasospasm,
initial vessel (CPT procedure code 61640) each additional vessel
in same family (CPT procedure code 61641) or different vascular
family (CPT procedure code 61642) is unproven.
3.11 Endoscopic thoracic sympathectomy.
3.12 Trigger point injection for migraine headaches.
3.13 Sphenopalatine ganglion block (CPT procedure
code 64505) for the treatment of chronic migraine headaches and
neck pain is unproven.
3.14 RF denervation (CPT procedure codes 64633,
64634) for the treatment of thoracic facet pain is unproven. Pulsed
Radiofrequency Ablation (RFA) for spinal pain is unproven.
3.15 Implantation of Occipital Nerve Stimulator
for the treatment of chronic intractable migraine headache is unproven.
3.16 Cryoablation of Occipital Nerve (CPT procedure
code 64640) for the treatment of chronic intractable headache is
unproven.
3.17 Spinal cord and deep brain
neurostimulation in the treatment of chronic intractable headache or
migraine pain is unproven.
3.18 Thermal Intradiscal Procedures (TIPs) (CPT
procedure codes 22526, 22527, 62287, and Healthcare Common Procedure
Coding System (HCPCS) code S2348) are unproven. TIPs are also known as:
Intradiscal Electrothermal Annuloplasty (IEA), Intradiscal Electrothermal
Therapy (IDET), Intradiscal Thermal Annuloplasty (IDTA), Percutaneous
Intradiscal Radiofrequency Thermocoagulation (PIRFT), Coblation
Percutaneous Disc Decompression, Nucleoplasty (also known as Percutaneous
RF thermomodulation or Percutaneous Plasma Diskectomy), Radiofrequency
Annuloplasty (RA), Intradiscal Biacuplasty (IDB), Percutaneous (or
Plasma) Disc Decompression (PDD), Targeted Disc Decompression (TDD),
Cervical Intradiscal RF Lesioning.
3.19 Laser ablation of paravertebral facet joint
nerves (CPT procedure codes 64622 and 64623) is unproven. (This
applies only to laser ablation and should not be applied to RFA.)
3.20 Minimally Invasive Lumbar Decompression (mild®)
for the treatment of Degenerative Disc Disease (DDD) and/or spinal
stenosis is unproven.
3.21 RFA
of the genicular nerves of the knee for the treatment of osteoarthritis
(OA) is unproven.
3.22 RFA for sacroiliac joint (SIJ)
denervation for the treatment of low back pain is unproven.
4.0 EFFECTIVE
DATES
4.1 January 1, 1989, for PAVM.
4.2 April 1,
1994, for therapeutic embolization for treatment of meningioma.
4.3 July 14,
1997, for GDC.
4.4 February 16, 2011, for endovascular coil occlusion
for embolizing intracranial aneurysms.
4.5 December 24, 2012, for FDD
treatment for intracranial aneurysms.
4.6 The date of FDA approval of the embolization
device for all other embolization procedures.
4.7 June 1, 2004, for Magnetoencephalography.
4.8 June 10, 2008, for thoracic epidural steroid
injections.
4.9 January 1, 2009, for non-pulsed
RF denervation for the treatment of chronic cervical and lumbar
facet pain.
4.10 January 1, 2009, for endoscopic
laminotomy for the treatment of lumbar spinal stenosis.
4.11 October 1, 2011, for vagus nerve stimulator
for treatment of LGS in children 12 years of age or younger.
4.12 March 14, 2011, for SNS for the treatment of
chronic fecal incontinence in patients who have failed or are not
candidates for more conservative treatment, and who have a weak
but structurally intact anal sphincter refractory to conservative
measures.
4.13 Effective July 27, 2012, for
implantation of a U.S. Food and Drug Administration (FDA) approved vagus
nerve stimulator, and battery replacement as adjunctive therapy
in reducing the frequency of seizures that are refractory to anti-epileptic
medications in beneficiaries under the age of 12.
4.14 August 9, 2012, for intracranial angioplasty.
4.15 February 2, 2014, for DBS for the treatment
of PD and ET.
4.16 September 3, 2016, for cervical
laminoplasty.