63655 — Electrical Nerve Stimulators

Electrical Nerve Stimulators (NCD 160.7)

CMS: “To meet coverage criteria, the patient’s medical record must contain documentation that fully supports the medical necessity of services. Subsections 6.2.1 to 6.2.13 list the documentation requirements for example services. For detailed documentation requirements, providers who choose to submit a prior authorization request for a WISeR Select Item or Service should refer to the relevant NCDs and/or their MAC jurisdiction’s LCDs and Local Coverage Articles (LCAs), if available, for guidance. They can be found on the Medicare Coverage Database website.”

For this NCD, WISeR will initially focus on spinal cord stimulators but will not overlap with or include CPT code 63650 for percutaneous implantation of spinal neurostimulators in CMS’ Prior Authorization Program for Certain Hospital Outpatient Department (OPD) Services.13 Prior authorization and pre-payment review are being implemented for the permanent implantation procedure. A trial procedure should be done, and documentation should be submitted for permanent implantation of a stimulator device. General documentation requirements for laminectomy for the implantation of a spinal cord stimulator for the relief of chronic intractable pain are as follows:

• ❑Documentation of condition requiring procedure and applicable physical exam
• ❑Documentation that stimulation is being used only as a late resort (if not a last resort) for patients with chronic intractable pain, including but not limited to at least one treatment tried and failed (or documentation that they were contraindicated): a) Medications b) Physical therapy c) Injections d) Spine surgery e) Cognitive behavioral therapy
• ❑Documentation showing that the patient was evaluated by a multidisciplinary team (including psychological,14 surgical, medical, and physical therapy)
• ❑Documentation showing that the patient achieved demonstrated reduction in pain and evidence of functional improvement with a temporarily implanted electrode
• ❑Documentation that the patient is not a candidate for percutaneously placed leads (e.g., previous instrumentation, challenging anatomy, high body mass index (BMI), other technical challenges), as WISeR does not include CPT 63650 for the trial or permanent implantation of spinal neurostimulators via the percutaneous approach.15

1. [13] CPT code 63650 for implanted spinal stimulator is included in CMS’ Prior Authorization Program for Certain Hospital Outpatient Department Services. For more information, please visit the Prior Authorization for Certain Hospital Outpatient Department Services webpage.
2. [14] See Medicare Learning Network (MLN1986542) booklet and Publication #100-2, Chapter 15, for more information on psychological evaluations.
3. [15] CPT code 63650 for implanted spinal stimulator is included in CMS’ Prior Authorization Program for Certain Hospital Outpatient Department Services. For more information, please visit the Prior Authorization for Certain Hospital Outpatient Department Services webpage.