1.0 CPT 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) 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 United States
(US) 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 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
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 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 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
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 code 61640) each additional vessel
in same family (CPT code 61641) or different vascular family (CPT
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 code 64505)
• Cryoablation of Occipital Nerve
(CPT code 64640)
• Deep brain neurostimulation
• Spinal cord neurostimulation
• Implantation of Occipital Nerve
Stimulator
3.13 Sphenopalatine ganglion block
(CPT code 64505) for the treatment of neck pain is unproven.
3.14 RF denervation (CPT 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 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 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 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 US 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.