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Chronic non-cancer pain is managed with a range of pharmacological, physical, psychological and surgical modalities. Peripheral nerve stimulation or neuromodulation has been proposed as a non-destructive surgical option for patients with refractory neuropathic pain affecting the trunk or limbs.
Use of a peripheral nerve stimulator involves implantation of electrodes around a selected peripheral nerve (e.g., radial, sciatic, ilioinguinal). The stimulating electrode is connected by an insulated lead to a receiver unit which is implanted under the skin at a depth not greater than 1/2 inch. Stimulation is induced by a generator connected to an antenna unit which is attached to the skin surface over the receiver unit.
As with other types of implantable nerve stimulation, implantation of the peripheral nerve stimulator is typically a two-step process. Initially, the electrode is temporarily implanted, allowing a trial period of stimulation. Once treatment effectiveness is confirmed (defined as at least 50% reduction in pain), the electrodes and radio-receiver/ transducer are permanently implanted.
Peripheral nerve (regional) field stimulation is a relatively recent application of peripheral neuromodulation. This type of stimulation, which involves placement of a stimulating electrode subcutaneously in the area of maximum pain, has been proposed as a treatment of low back pain.
The U. S. Food and Drug Administration (FDA) has approved the StimQ Peripheral Nerve Stimulator (PNS) system for use in adults with “severe intractable chronic pain of peripheral origin, as the sole mitigating agent, or as an adjunct to other modes of therapy used in a multidisciplinary approach.” Another device, the StimRouter Neuromodulation System, gained 510(k) clearance for “pain management in adults who have severe intractable chronic pain of peripheral nerve origin, as an adjunct to other modes of therapy (e.g., medications).” The SPRINT peripheral nerve stimulation device received FDA clearance as a temporary implant for the treatment of post-traumatic pain, post-operative pain, and chronic, intractable pain.
NOTE: Occipital Nerve Stimulation is addressed separately in policy II-140.
Peripheral nerve stimulation of the trunk or limbs, including but not limited to stimulation of the radial, sciatic, and ilioinguinal nerves, is considered EXPERIMENTAL/INVESTIGATIVE for the treatment of all acute and chronic pain indications due to a lack of evidence demonstrating its impact on improved health outcomes.
Peripheral nerve (regional) field stimulation is considered EXPERIMENTAL/INVESTIGATIVE for the treatment of chronic pain due to a lack of evidence demonstrating its impact on improved health outcomes.
No additional statements.
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
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Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
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Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.
