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A.7.01.139
Peripheral subcutaneous field stimulation is a form of neuromodulation intended to treat chronic neuropathic pain. Applications of peripheral subcutaneous field stimulation being evaluated are craniofacial stimulation for headache and migraine, craniofacial pain, or occipital neuralgia. Peripheral subcutaneous field stimulation is also being investigated for low back pain, neck and shoulder pain, inguinal and pelvic pain, thoracic pain, abdominal pain, fibromyalgia, and post-herpetic neuralgia.
Chronic Pain
Chronic, non-cancer pain is responsible for a high burden of illness. Common types of chronic pain are lumbar and cervical back pain, chronic headaches, and abdominal pain. All of these conditions can be challenging to treat.
TreatmentPharmacologic agents are typically the first-line treatment for chronic pain, and several classes of medications are available. These include analgesics (opioid and non-opioid), antidepressants, anticonvulsants, and muscle relaxants. A variety of non-pharmacologic treatments also exist, including physical therapy, exercise, cognitive-behavioral interventions, acupuncture, chiropractic, and therapeutic massage.
Neuromodulation, a form of non-pharmacologic therapy, is usually targeted toward patients with chronic pain refractory to other modalities. Some forms of neuromodulation, such as transcutaneous electrical nerve stimulation and spinal cord stimulation, are established methods of chronic pain treatment. Peripheral nerve stimulation, which involves placement of an electrical stimulator on a peripheral nerve, is also used for neuropathic pain originating from peripheral nerves.
Peripheral Subcutaneous Field Stimulation
Peripheral subcutaneous field stimulation is a modification of peripheral nerve stimulation. In peripheral subcutaneous field stimulation, leads are placed subcutaneously within the area of maximal pain. The objective of peripheral subcutaneous field stimulation is to stimulate the region of affected nerves, cutaneous afferents, or the dermatomal distribution of the nerves, which then converge back on the spinal cord. Combination spinal cord stimulation plus peripheral subcutaneous field stimulation is also being evaluated.
Similar to spinal cord stimulation or peripheral nerve stimulation, permanent implantation is preceded by a trial of percutaneous stimulation with at least 50% pain reduction. Currently, there is no consensus on the indications for peripheral subcutaneous field stimulation. Criteria for a trial of peripheral subcutaneous field stimulation may include a clearly defined, discrete focal area of pain with a neuropathic or combined somatic/neuropathic pain component with characteristics of burning and increased sensitivity, and failure to respond to other conservative treatments including medications, psychological therapies, physical therapies, surgery, and pain management programs.
The mechanism of action in peripheral subcutaneous field stimulation is unknown. Theories include an increase in endogenous endorphins and other opiate-like substances; modulation of smaller A delta and C nerve fibers by stimulated large-diameter A beta fibers; local stimulation of nerve endings in the skin; local anti-inflammatory and membrane-depolarizing effect; or a central action via antegrade activation of A beta nerve fibers. Complications of peripheral subcutaneous field stimulation include lead migration or breakage and infection of the lead or neurostimulator.
Peripheral subcutaneous field stimulation is an off-label use of peripheral nerve stimulation systems that have been approved by the Food and Drug Administration for the treatment of chronic pain by targeting one or more peripheral nerves associated with pain.
Peripheral subcutaneous field stimulation is investigational.
Federal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
07/18/2013: Approved by Medical Policy Advisory Committee.
04/29/2014: Policy reviewed; no changes.
04/06/2015: Policy description and statement unchanged. Policy guidelines updated to revise investigative definition.
08/04/2015: Code Reference section updated for ICD-10.
05/31/2016: Policy number A.7.01.139 added.
06/27/2016: Policy description updated. Policy statement unchanged.
12/30/2016: Code Reference section updated to note deleted codes and add CPT code 64999.
05/02/2017: Policy description updated. Policy statements unchanged.
05/09/2018: Policy reviewed. Policy statement unchanged. Code Reference section updated to remove deleted CPT codes 0282T, 0283T, 0284T, and 0285T.
05/10/2019: Policy description updated regarding devices. Policy statement unchanged.
06/10/2020: Policy reviewed; no changes.
07/15/2021: Policy reviewed; no changes.
05/31/2022: Policy reviewed; no changes.
05/12/2023: Policy description updated regarding devices. Policy statement unchanged.
05/20/2024: Policy description updated regarding peripheral subcutaneous field stimulation. Policy statement unchanged.
05/08/2025: Policy reviewed; no changes.
Blue Cross and Blue Shield Association Policy # 7.01.139
This may not be a comprehensive list of procedure codes applicable to this policy.
Code Number | Description |
CPT-4 | |
64999 | Unlisted procedure, nervous system |
HCPCS | |
ICD-10 Procedure | |
ICD-10 Diagnosis |
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