Contact Us
Plans and Services Health and Wellness About Wellmark Member Employer Producer Provider
Home Provider Medical Policies and Authorizations Alphabetical Listing


» Working with Wellmark.com
» News
» BlueCard®
» Claims and Payment
» Medical Policies and Authorizations
» Health Management
» Credentialing and Contracting
» Medical, Dental, and Pharmacy
» Quality and Transparency
» Communications and Resources
» Health Care Reform for Providers

Spinal Cord Stimulation

» Summary» Procedure Codes
» Description» Selected References
» Prior Approval» Policy History
» Policy
 

Medical Policy: 07.01.61 
Original Effective Date: November 2000 
Reviewed: October 2014 
Revised: February 2015 


Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.


Description: 

Spinal cord stimulation (SCS), also known as dorsal column stimulator (DCS) delivers a low voltage electrical current continuously to the dorsal columns of the spinal cord to block the sensation of pain. The neurophysiology of pain relief after SCS is uncertain but may be related to either activation of an inhibitory system or blockage of facilitative circuits. SCS is the most commonly used implantable neurostimulation technology for the management of pain syndromes.

 

Spinal cord stimulation (SCS) devices consists of several components: (1) the lead that delivers the electrical stimulation to the spinal cord; (2) an extension wire that conducts the electrical stimulation from the power source to the lead; and (3) a power source that generates the electrical stimulation. The lead may incorporate from 4 to 8 electrodes, with 8 electrodes more commonly used for complex pain patterns, such as bilateral pain or pain extending from the limbs to the trunk. Totally implantable systems are the most commonly used.

 

There are three types of SCS devices:

  • Conventional Systems: (total implantable system): The leads are inserted in the epidural space above the spinal cord using a small needle or through a small incision. The exact location of the lead(s) depends on the specificity of the patients pain. The generator is usually implanted in the abdomen or buttock region. This system requires little effort on the patient’s part for maintenance. However, a minor surgical procedure is required to replace the power source when it runs out.
  • Radiofrequency Systems: Are designed to sustain therapy over long periods at the highest output level. Because of its high power capabilities, the RF system is suitable for the most challenging cases in which there is complex, multi-extremity pain. With this type of system, the patient must wear an external power source to activate stimulation.
  • Rechargeable Systems: Are the newest type of SCS device. The patient is responsible for recharging the power source when it runs low. A rechargeable system typically lasts longer than a conventional System. Eventually a minor surgical procedure may be required to replace the power source if the time between recharges becomes impractical.

SCS has been used in a wide variety of chronic refractory pain conditions, including pain associated with cancer, pain that is neuropathic in nature such as failed back pain syndromes, arachnoiditis, and complex regional pain syndrome (CRPS) (i.e. chronic reflex sympathetic dystrophy). There has been an interest in SCS as a treatment of critical limb ischemia, primarily in patients who are poor candidates for revascularization and in patients with refractory chest pain. 

 

Pain Neuropathic in Nature
SCS is used for the treatment of pain that is neuropathic in nature, ie. resulting from damage to the peripheral nerves. Common indications include, but are not limited to failed back syndrome (lumbar or cervical), complex regional pain syndrome (i.e. reflex sympathetic dystrophy), arachnoiditis, radiculopathies, phantom limb/stump pain and peripheral neuropathy. 

 

Nociceptive Pain and Central Deafferentation Pain
Based on the peer reviewed literature spinal cord stimulation is generally not effective in treating nociceptive (pain which results from irritation, not damage to the nerves), or for central deafferentation pain (related to central nervous system damage from a stroke or spinal cord injury). The use of spinal cord stimulation for these indications would be considered investigational. 

 

Chronic Limb or Trunk Pain
The evidence on SCS for the treatment of chronic limb or truck pain consists of a number of small RCTs that include patients with refractory pain due to conditions such as failed back surgery and CRPS (reflex sympathetic dystrophy). These studies are heterogenous in terms of patient populations and outcomes, but generally reported an improvement in pain and a reduction in requirement of medications. Because these patients have few other options, the evidence suggests that SCS is a reasonable treatment option.

 

Critical Limb Ischemia
Critical limb ischemia is described as pain at rest or the presence of ischemic limb lesions. If the patients are not suitable candidates for limb revascularization, it is estimated that amputation will be required in a substantial number of patients. SCS has been investigated as a technique to relieve pain and decrease incidence of amputation.

 

Based on the literature there are five relatively small RCTs for SCS versus usual care that have been completed on patients with critical limb ischemia. SCS did not result in a significantly lower rate of amputation and therefore, the evidence is not sufficient to conclude that SCS improves outcomes for patients with critical limb ischemia and is considered investigational.

 

Refractory Angina Pectoris
Numerous small RCTs have evaluated SCS as a treatment for refractory angina. Some studies have reported a benefit, the majority have not. More recent RCTs that enrolled more than 100 patients, there was no benefit on the primary outcomes. Overall, this evidence is mixed and not sufficient to allow conclusions on whether health outcomes are improved and therefore, would be considered investigational.

 

Cancer Related Pain  
In a 2013, a Cochrane review was published on SCS for treatment of cancer related pain in adults. The author did not identify any RCTs evaluating the efficacy of SCS in patients with cancer related pain. Four case series using a before-after design with a total of 92 patients were identified. However, in the absence of controlled studies, the efficacy of SCS for treating cancer related pain cannot be determined and considered investigational. 

 

Patients being considered for spinal cord stimulation should ideally meet the following criteria:

  • Pain is not associated with malignancy
  • Poor response to conservative treatment for a minimum of 6 months
  • Revision surgery not an option or would have a low chance of success
  • No pacemaker or other medical contraindications
  • No major psychiatric disorders, including somatization
  • Willingness to stop inappropriate drug usage prior to implantation
  • Ability to give informed consent for the procedure 

Spinal cord stimulation is used only as a last resort; other treatment modalities (pharmacological, surgical, psychological or physical, if applicable) have been tried and failed or are judged to be unsuitable or contraindicated.

 

Implantation of the spinal cord stimulator device is typically a 2 step process:

 

Spinal Cord Stimulator Trial
The first step is to implant a device on a trial basis which is done in an outpatient visit. The patient’s skin is numbed with a local anesthetic; leads are placed under the skin and attached to a small generator that the patient carries (much like a pager or cell phone); and using pre-set programs, electrical  currents are emitted in a pattern to target the areas of pain. The trial phase can be beneficial for the following reasons:

  • It can help the patient/physician analyze whether SCS effectively relieves pain.
  • It provides the patient/physician with an assessment period to determine which types of SCS technology works best.
  • It enables the patient/physician to evaluate different stimulation settings and programs.

The individual will keep a written log of the stimulation settings during different activities, along with the level of pain relief. If the trail is successful then a permanent spinal cord stimulator may be implanted. 

 

Permanent Spinal Cord Stimulator
If the SCS trial provides adequate pain relief (demonstrates a reduction in pain of at least 50% or more during the trial period), then a permanent system may be implanted. SCS is reversible therapy, even though it is called permanent, treatment can be discontinued at any time and the implanted parts turned off or removed.

 

Practice Guideline and Position Statements
In October 2008, The National Institute for Health and Clinical Excellence (NICE) issued a guideline on spinal cord stimulation for chronic pain of neuropathic or ischemic origin. The guideline stated that SCS is recommended as a treatment option for adults with chronic pain of neuropathic origin who continue to experience pain chronic pain (measuring at 50 mm on a 0-100 mm VAS) for at least 6 months despite appropriate conventional medical management, and who have had a successful trial of stimulation as part of an assessment by a specialist team.

 

Spinal cord stimulation is not recommended as a treatment option for adults with chronic pain of ischemic origin except in the context of research as part of a clinical trial.

 

In 2013, The American Society of Interventional Pain Physicians updated their evidence based guidelines for interventional techniques in the management of chronic spinal pain. The guidelines included the statement that there is fair evidence in support of SCS in managing patients with failed back syndrome.

 

Regulatory Status
Permanently implanted spinal cord stimulator devices are approved for marketing by the U.S. Food and Drug Administration (FDA) under the premarket approval (PMA) process; temporary devices used to determine a patient’s eligibility for a permanent implant are cleard under the 510(k) premarket notification process.    

 

The Cordis programmable neurostimulator from Cordis Corp. was approved in 1981, and the Itrel manufactured by Medtronic was approved in 1984. In April 2004, Advanced Bionics received PMA for its Precision Spinal Cord Stimulator as an aid in management of chronic, intractable trunk and limb pain. All are fully implantable devices.


Top


Prior Approval: 

Not applicable


Top


Policy: 

Implantation of a Temporary (Trial) Spinal Cord Stimulation (SCS) Device
A trial period using a temporary spinal cord stimulator device may be considered medically necessary when all of the following criteria are met:

 

An individual has undergone careful screening, including evaluation by a multi-disciplinary team that confirms the existence of one of the following conditions:

  • Failed back syndrome (lumbar and cervical) or post-laminectomy syndrome (lumbar and cervical)
  • Complex regional pain syndrome, type I or type II (formerly known as reflex sympathetic dystrophy (RSD)) 
    • Type I CRPS is associated with symptomatic tissue injury
    • Type II CRPS is associated with nerve injury
  • Chronic neuropathic pain of certain origins (last resort treatment of moderate or severe pain (5 or more on a 10-point Visual Analog Scale (VAS) or the Numeric Pain Intensity Scale)):
    • Lumbosacral arachnoiditis (arachnoiditis is usually documented by the presence of high levels of proteins in the cerebrospinal fluid and/or by myelography or MRI); OR
    • Radiculopathy; OR
    • Phantom limb syndrome (stump pain); OR
    • Peripheral neuropathy; OR
    • Patients with chronic back pain (neuropathic pain) who are non-surgical candidates; and

Documentation in the medical record of the failure of 6 months of conservative treatment modalities (pharmacologic, surgical, psychological or physical therapies), if appropriate and not contraindicated; and

 

Further surgical intervention is not indicated; and

 

Psychological evaluation has been obtained and there is documentation stating the pain is not psychologic in origin; and

 

There is no evidence of existing untreated drug addiction; and

 

No contraindications to implantation exist (i.e. sepsis or coagulopathy issues).

 

Implantation of Permanent Spinal Cord Stimulation (SCS) Device
Placement of a permanent spinal cord stimulator device may be considered medically necessary when the above medical necessity criteria for a trial placement of spinal cord stimulation are met, and the patient has demonstrated the following:

  •  Pain relief of at least 50% or more since the starte of the trial period of the termporary SCS device as documented in the medical record; and
  • There is objective evidence (documentation in the medical records) of pain relief (eg, decreased opioid usage, improved range of motion of the affected area, increased activity, increased pain relief according to the Visual Analog Scale [VAS] or the Numeric Pain Intensity Scale).

Replacement of Spinal Cord Stimulator Device

 

Replacement of spinal cord stimulator and/or battery/generator may be considered medically necessary for an individual that meets the above medical necessity criteria and the existing stimulator and/or battery/generator are/is no longer under warranty and cannot be replaced.

 

Removal or Revision of Spinal Cord Stimulator Device

 

The removal or revision of a spinal cord stimulator device may be considered medically necessary for any of the following indications:

  • Migration of lead(s)
  • Loss of effectiveness
  • Intolerance by individua
  • lInfection
  • Painful generator site
  • Need for AICD (automatic implantable cardioverter defibrillator)
  • Development of neurological deficits
  • Need for MRI study

Spinal cord stimulation is considered investigational for all other indications including but not limited to the following because the safety and effectiveness cannot be established by review of the available published peer reviewed literature:

  • Treatment of cancer related pain
  • Treatment of peripheral vascular disease
  • Treatment of chronic pain of ischemic origin:
    • Treatment of critical limb ischemia as a technique to forestall amputation
    • Treatment of refractory angina pectoris
  • Treatment of Multiple Sclerosis & spasticity disorders
  • Treatment of axial and other musculoskeletal pain syndromes
  • Treatment of scoliosis
  • Treatment of nociceptive pain (resulting from irritation, not damage to nerves)
  • Treatment of central deafferentation pain (related to central nervous  system damage from a stroke or spinal cord injury)
  • Treatment of postherpatic neuralgia
  • Cervical spinal cord stimulation except as indicated above

Definitions
Arachnoiditis:
Painful condition caused by inflammation of the arachnoid, one of the three linings that surround and protect the brain and the spinal cord. The arachnoid can become inflamed due to a variety of reasons. These include irritation from chemicals present myelograms and epidural steroid injections; bacterial or viral infections; spinal cord injury; or complications from spinal surgery or other invasive spinal procedures. When arachnoiditis begins to impact the nerves, it can cause a number of symptoms, including numbness, tingling, and a distinctive stinging and burning pain the lower back and legs. Other symptoms may include debilitating muscle crams, twitches, spasms and bladder/bowel/sexual dysfunction. There is no cure for this condition, so the goal of treatment is to control pain and symptoms.

 

Arachnoiditis is usually documented by the presence of high levels of proteins in the cerebrospinal fluid and/or by myelography or magnetic resonance imaging.

 

Complex Regional Pain Syndrome (CRPS): Is an uncommon nerve disorder which causes intense burning pain, usually in the arms, hands, legs or feet. It can occur after an injury, either to a nerve or to tissue in the affected area. Along with pain, the patient may experience extreme skin sensitivity and changes in color, temperature or moistness of the skin. The cause of CRPS is unknown, and there is no cure.

 

Failed Back Syndrome (FBSS) or post laminectomy syndrome (lumbar or cervical):
Is persistent or recurrent pain, mainly involving the lower back and/or legs, even after prior anatomically successful spinal surgery. FBSS is considered a diagnosis of exclusion, so CT scans or MRIs must demonstrate that there are no surgically correctable lesions present. Patients with FBSS often have epidural/intraneural/perineural fibrosis or scar tissue, which generally will not respond to surgery but may respond to spinal cord stimulator (SCS).

    

Neuropathic Pain: Otherwise known as “nerve pain” is a complex, chronic pain state that usually is accompanied by tissue injury. With neuropathic pain, the nerve fibers themselves might be damaged, dysfunctional or injured. These damaged nerve fibers send incorrect signals to other pain centers. The impact of nerve fiber injury includes a change in nerve function both at the site of injury and areas around the injury.

 

Nociceptive Pain: Nociceptors are the nerves which sense and respond to parts of the body which suffer from damage. They signal tissue irritation, impending injury or actual injury. When activated they transmit pain signals (via the peripheral nerves as wella s the spinal cord) to the brain. The pain is typically well localized, constant and often with an aching throbbing quality. Visceral pain is the subtype of nociceptive pain that involves the internal organs. It tends to be episodic and poorly localized.

 

Nociceptive pain is usually time limited, meaning when the tissue damage heals, the pain typically resolves.


Central Deafferentation Pain: Central pain is defined as pain that is initiated by a primary lesion within the CNS. Central pain can occur in association with all types of CNS lesions related to wide variety of pathological processes. Deafferentation pain denotes a type of pain that results from complete or partial interruption of afferent nerve impulses. This type of pain results from lesions that interrupt the spinothalmic pathways at any level of the nervous system.

 

Patients with deafferentation pain usually display varying degrees of sensory loss characterized by disturbances with pain and temperature sensation.

     

Critical Limb Ischemia (CLI): Is a severe blockage in the arteries of the lower extremities, which markedly reduces blood-flow. It is a serious form of peripheral arterial disease, or PAD. CLI is a chronic condition that results in severe pain in the feet or toes, even while resting. Complications of poor circulation can include sores and wounds that won't heal in the legs and feet. Left untreated, the complications of CLI will result in amputation of the affected limb.

 

Refractory Angina Pectoris: Is a chronic condition characterized by the presence of angina caused by coronary insufficiency in the presence of coronary artery disease which cannot be controlled by a combination of medical therapy, angioplasty and coronary bypass surgery. The presence of reversible myocardial ischemia should be clinically established to be the cause of the symptoms. Chronic is defined as a duration of more than 3 months.

 

Ischemic Pain: Is caused by a reduction in oxygen delivery to the tissue, usually caused by reductive in blood flow because of construction of blood vessel (vasospasm) or its obstruction by atheroma or embolus. Ischemic pain conditions include critical limb ischemia & refractory angina).  





Top


Procedure Codes and Billing Guidelines: 

  • To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
  • 63650 Percutaneous implantation of neurostimulator electrode array, epidural
  • 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural
  • 63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed
  • 63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed
  • 63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed
  • 63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed
  • 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
  • 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver
  • C1767 Generator neurostimulator (implantable) non-rechargeable
  • C1778 Lead, neurostimulator
  • C1787 Patient programmer, neurostimulator
  • C1816 Receiver and/or transmitter neurostimulator (implantable)
  • C1820 Generator neurostimulator (implantable with rechargeable battery and charging system)
  • C1897 Lead neurostimulator test kit (implantable)
  • L8679 Implantable neurostimulator, pulse generator any type
  • 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, nonrechargeable, includes extension
  • L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
  • L8688 Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension
  • L8689 External recharging system for battery (internal)for use with implantable neurostimulator, replacement only
  • 95970 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse 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, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming
  • 95971 Simple spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter with intraoperative or subsequent programming, first hour
  • 95972 Complex spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) (except cranial) neurostimulator pulse generator/transmitter with intraoperative and subsequent programming, first hour
  • 95973 Complex spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) (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)   

Top


Selected References: 

Wellmark's policy is based on:

  • ECRI. Rechargeable Spinal Cord Stimulation Systems for Chronic Pain Control. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 March 20. 11 p. (ECRI Hotline Response).
  • UpToDate. Prevention and Management of Complex Regional Pain Syndrome in Adults. Salahadin Abdi, M.D., PhD. Topic Last Updated November 18, 2013.
  • UpToDate. Overview of Chronic Pain. Ellen WK Rosenquist, M.D.. Topic Last Updated September 26, 2013.
  • UpToDate. New Therapies for Angina Pectoris. Michael Simons, M.D., Roger J. Laham, M.D.. Topic Last Updated September 23, 2013.
  • UpToDate. Treatment of Chronic Lower Extremity Critical Limb Ischemia. David G. Neschis, M.D., Michael A. Golden,M.D.. Topic Last Updated October 25, 2012.
  • National Institute of Health, National Institute of Neurological Disorders and Stroke. Arachnoiditis Information Page.
  • ECRI. Rechargeable Spinal Cord Systems for Managing Chronic Pain. ECRI Hotline Response. February 2013.
  • National Institute of Health and Clinical Excellence (NICE). Spinal Cord Stimulation for Chronic Pain of Neuropathic or ischemic Origin. Issue date: October 2008. Review date: November 2011
  • Agency for Healthcare Research and Quality (AHRQ). Practice Guideline for Chronic Pain Management. American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine.
  • American Association of Neurological Surgeons (AANS). Patient Information. Spinal Cord Stimulation. October 2008.
  • American Society of Interventional Pain Physicians (ASIPP) and Interventional Pain Management (IPM). Comprehensive Evidence Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain. Pain Physician 2009; 12:699-802.
  • National Guideline Clearinghouse: 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease. J AM Coll Cardiol. 2012 Dec 18; 60(24):e44-e164.
  • American Chronic Pain Association: Chronic Pain Medication & Treatment 2014 Edition. Also available at www.theacpa.org
  • Centers for Medicare and Medicaid Services. National Coverage Determination for Electrical Stimulators (160.7). Also available at www.cms.gov
  • Medtronic www.medtronic.com
  • American Pain Society (APS). APS Clinical Guideline for Evaluation and Management of Low Back Pain. Also available at www.americanpainscociety.org
  • American Association of Neurological Surgeons (AANS). Patient Information, Spinal Cord Stimulation. October 2008. Also available at www.aans.org
  • Institute for Clinical Systems Improvement (ICSI), Assessment and Management of Chronic Pain. Updated November 2013. Also available at www.icsi.org
  • North American Neuromodulation Society, Neuromodulation Therapy Access Coalition Position Statement on Spinal Cord Neurostimulation. Also available at www.neuromodulation.org
  • North American Neuromodulation Society, Painful Peripheral Neuropathy. Also available at www.neuromodulation.org
  • ECRI. Hotline Response Spinal Cord Stimulation for Treatment Peripheral Neuropathy, March 2014. Also available at http://www.ecri.org
  • Medscape Spinal Cord Stimulation: Indications and Outcomes. Also available at www.medscape.com
  • Medscape Spinal Cord Stimulation. Updated June 26, 2012. Also available at http://emedicine.medscape.com
  • Medscape Spinal Cord Stimulation “Last Resort” for Diabetic Nerve Pain, Miriam E. Tucker, September 30, 2014. Also available at www.medscape.com
  • PubMed, De Vries J, et. al. Spinal Cord Stimulation for Ischemic Heart Disease and Peripheral Vascular Disease. Adv Tech Stand Neurosurg 2007;32:63-89. Also available at www.ncbi.nlm.nih.gov
  • PubMed, Vallejo R, et. al. Neuromodulation of the Cervical Spine Cord in the Treatment of Chronic Intractable Neck and Upper Extremity Pain: A Case Series and Review of the Literature. Pain Physician 2007 Mar;10(2):305-11. Also available at www.ncbi.nlm.nih.gov
  • PubMed, Dausi C, et. al. Electrical Spinal Cord Stimulation in the Long Term Treatment of Chronic Painful Diabetic Neuropathy. Diabet Med 2005 Apr;22(4):393-8. Also available at www.ncbi.nlm.nih.gov
  • PubMed, de Vos CC, et. al. Spinal Cord Stimulation in Patients with Painful Diabetic Neuropathy: A Multicenter Randomized Clinical Trial. Pain 2014 Aug 29. Also available at www.ncbi.nlm.nih.gov
  • Pain Medicine News, Neuropathic Pain of Postherpatic Neuralgia. Also available at www.painmedicinenews.com
  • Cocharane Data Base of Systemic Reviews Publisher John Wiley & Sons, Ltd. Publication February 28, 2013, Spinal Cord Stimulation for Cancer Related Pain in Adults. Also available at http://www.evidence.nhs.uk/document
  • UpToDate. Investigational Therapies for Treating Symptoms of Lower Extremity Peripheral Artery Disease, Emile R. Mohler III, M.D., Topic last updated July 30, 2014. Also available at www.uptodate.com
  • UpToDate Subacute and Chronic Low Back Pain: Surgical Treatment, Roger Chou, M.D., Topic last updated May 30, 2014. Also available at www.uptodate.com
  • UpToDate Prevention and Management of Complex Regional Pain Syndrome in Adults, Salahadin Abdi, M.D., PhD., Topic last updated August 7, 2014. Also available at www.uptodate.com
  • UpToDate Overview of the Treatment of Chronic Pain, Ellen WK Rosenquist, M.D., Topic last updated September 19, 2014. Also available at www.uptodate.com
  • UpToDate Treatment of Cervical Radiculopathy, Jenice Robinson, M.D., Milind J. Kothari, M.D.. Also available at www.uptodate.com
  • UpToDate Brachial Plexus Syndrome, Mark B. Bromberg, M.D., PhD. Topic last updated August 19, 2013. Also available at www.uptodate.com
  • UpToDate New Therapies for Angina Pectoris, Michael Simons, M.D., Roger J Latham, M.D., Topic last updated September 11, 2014. Also available at www.uptodate.com
  • UpToDate Cancer Pain Management: Interventional Therapies, Ronald Kaplan M.D., Russell K. Portenoy, M.D., Topic last updated August 30, 2013. Also available at www.uptodate.com
  • UpToDate. Adolescent Idiopathic Scoliosis: Treatment of Prognosis, Susan A. Scherl, M.D., Topic last updated September 2, 2014. Also available at www.uptodate.com
  • UpToDate Postherpatic Neuralgia, Zahid H. Bajwa, M.D., Carol A. Warfield, M.D., Dana G. Crovo, M.D., Topic last updated October 24, 2014, Also available at www.uptodate.com
  • International Modulation Society (INS), Spinal Cord Stimulation for Neuropathic Pain. Also available at www.neuromodulation.com        

Top


Policy History: 

Date                                   Reason                              Action

October 2010                    Annual review                   Policy renewed
February 2011                   Interim review                   Policy revised
January 2012                     Annual review                   Policy renewed
January 2013                     Annual review                   Policy renewed
January 2014                     Annual review                  Revision and new policy created

May 2014                          Interim review                  Policy revised

October 2014                    Annual review                  Policy revised

February 2015                                                         Policy revised


Top


Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.

 
Contact Information
New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
  Wellmark Blue Cross and Blue Shield
  Medical Policy Analyst
  P.O. Box 9232
  Des Moines, IA 50306-9232
FacebookTwitterInstagrampinterestLinked InYou Tube