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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).
Spinal Cord Stimulation (SCS) for the Treatment of Intractable Angina Pectoris is considered investigational.
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 HISTORY2/2001: 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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.