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 The following treatments for chronic intractable
headache or migraine pain are unproven:
• Trigger point
injection
• Sphenopalatine
ganglion block (CPT procedure code 64505)
• Cryoablation
of Occipital Nerve (CPT procedure code 64640)
• Deep brain neurostimulation
• Spinal cord
neurostimulation
• Implantation
of Occipital Nerve Stimulator
3.13 Sphenopalatine
ganglion block (CPT procedure code 64505) for the treatment of 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 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.
3.16 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.)
3.17 Minimally
Invasive Lumbar Decompression (mild®) for the treatment of Degenerative
Disc Disease (DDD) and/or spinal stenosis is unproven.
3.18 RFA
of the genicular nerves of the knee for the treatment of osteoarthritis
(OA) is unproven.
3.19 RFA for sacroiliac joint (SIJ) denervation
for the treatment of low back pain is unproven.
3.20 Transcutaneous
Electrical Nerve Stimulation (TENS) for the treatment of acute,
subacute, and chronic low back pain (LBP) is excluded from coverage.
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.
4.17 June
1, 2020, for the exclusion of TENS for the treatment of acute, subacute,
and chronic LBP.