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Printer Friendly Version Spinal Cord Stimulation (SCS) for the Treatment of Intractable Angina Pectoris

Spinal Cord Stimulation (SCS) for the Treatment of Intractable Angina Pectoris

DESCRIPTION

Spinal cord stimulation (SCS) uses electrical impulses from pre-positioned electrodes in the epidural space of the dorsal column of the spinal cord to suppress pain with chronic intractable angina pectoris. Spinal cord stimulation (SCS) is proposed as a late or last resort treatment.

SCS implantation is performed in a procedure room equipped with x-ray fluoroscopic instrumentation. The patient is placed prone on a table and a local anesthetic is given. A Tuohy needle is used to insert the electrodes into the dorsal epidural space in the mid to upper thoracic area. The electrode tip is positioned between the seventh cervical vertebra and the second thoracic vertebra, under radiographic guidance. The placement of the electrode varies according to where the patient feels the anginal pain. It is important that the area in which is covered by the paresthesia, often described by the patient as a prickling or tingling sensation when the stimulator is operational, is the same area where the patient feels the anginal pain. A temporary stimulator is attached to the electrodes, and the patient verbally guides the clinician until the area of paresthesia matches the area of pain. An electrodedisplacement of only 1 to 2 millimeters can have a large influence on the efficacy of the SCS. When the area of paresthesia is localized to the same area as the referred pain, the electrodes are anchored and an extension wire is tunneled to a subcutaneous "pocket" created in the abdomen. Implantation of the pulse generator into the pocket is performed, and the generator is attached to the extension wire. The patient can activate the pulse generator at will either with a magnet that is passed over the skin at the area of the subcutaneous pocket or through a patient programmer that sends radio signals to the generator (Augustinsson et al., 1996).

POLICY

Spinal Cord Stimulation (SCS) for the Treatment of Intractable Angina Pectoris is considered investigational.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

POLICY HISTORY

2/2001: Approved by Medical Policy Advisory Committee (MPAC)

2/14/2002: Investigational definition added

5/7/2002: Type of Service and Place of Service deleted

10/19/2005: Code Rerference section updated; CPT-4 63655, 63685, 95970, 95971, 95972, 95973 added; ICD-9 Procedure 86.09, 86.94, 86.95, 86.96 added; ICD-9 Diagnosis: " Spinal cord stimulation is not eligible for coverage when used for the treatment of intractable angina pectoris. For other conditions, see the Spinal Cord Stimulation medical policy." added; HCPCS: E0752, E0754, E0756, E0757, E0758 added

11/15/2005: ICD9 procedure codes 86.97, 86.98 added

3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy

4/11/2006: Policy reviewed, no changes

12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions

12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions

SOURCE(S)

Hayes Medical Technology Directory

CODE REFERENCE

All codes are considered investigational and not eligible for coverage.

Non-Covered Codes

Code Number	Description
CPT-4
63650	Percutaneous implantation of neurostimulator electrode array, epidural
63655	Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural
63660	Revision or removal of spinal neurostimulator electrode percutaneous array(s) or plate/paddle(s) (Deleted 12/31/2009)
63661	Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy when performed (New 1-1-2010)
63662	Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (New 1-1-2010)
63663	Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (New 1-1-2010)
63664	Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (New 1-1-2010)
63685	Insertion or replacement of spinal neurostimulator puslse generator or receiver, direct or inductive coupling
63688	Revision or removal of implanted spinal neurostimulator pulse generator or receiver
95970	Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (ie, cranial nerve, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming
95971	Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple spinal cord, or peripheral (ie, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming
95972	Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour
95973	Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)
ICD-9 Procedure
03.93	Insertion or placement of spinal neurostimulator
03.94	Removal of spinal neurostimulator
86.09	Other incision of skin and subcutaneous tissue
86.94	Insertion or replacement of single array neurostimultor pulse generator
86.95	Insertion or replacement of dual array neurostimulator pulse generator
86.96	Insertion or replacement of other neurostimulator pulse generator
86.97	Insertion or replacement of single array rechargeable neurostimulator pulse generator
86.98	Insertion or replacement of dual array rechargeable neurostimulator pulse generator
ICD-9 Diagnosis
413.0, 413.1, 413.9	Angina pectoris code range Spinal cord stimulation is not eligible for coverage when used for the treatment of intractable angina pectoris. For other conditions, see the Spinal Cord Stimulation medical policy.
HCPCS
L8680	Implantable neurostimulator electrode, each
L8681	Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only
L8682	Implantable neurostimulator radiofrequency receiver
L8683	Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
L8685	Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
L8686	Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension
L8687	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
L8688	Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension

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