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.
3.21 Functional Electrical
Stimulation (FES) for the treatment of foot drop in Multiple Sclerosis
(MS) and post stroke patients is considered unproven.
3.22 FES for the treatment
of non-traumatic spinal cord injury from Transverse Myelitis (TM)
in children and adolescents is considered 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.
4.17 June 1, 2020, for the exclusion
of TENS for the treatment of acute, subacute, and chronic LBP.