Medical Policy: 07.01.78 

Original Effective Date: October 2018 

Reviewed: October 2018 

Revised:  

 

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:

Implantable peripheral nerve stimulation for chronic pain of peripheral nerve origin is a type of neuromodulation therapy that involves the surgical implantation of electrodes that target peripheral nerves considered to be the origin of pain. This procedure differs from other forms of peripheral nerve stimulation, because of the origin of pain is from a peripheral nerve and the electrical impulses are delivered to the nerve versus surrounding tissues or the spine.

 

Implantable peripheral nerve stimulation varies from other electrical stimulation therapies:

  • Spinal cord stimulation (SCS) delivers electrical impulses to the spine versus directly to the peripheral nerve pain site. 
  • Transcutaneous electrical nerve stimulation (TENS) delivers pulses below the skin, to alleviate pain. 
  • Percutaneous electrical nerve stimulation (PENS) is similar to TENS, except PENS requires electrodes to be inserted into the skin. 
  • Percutaneous neuromodulation therapy (PNT) is similar to PENS, but PNT is an electrical stimulation therapy using very thin needle electrodes that are inserted directly into the deep tissues in the area causing pain.     
  • Peripheral subcutaneous field stimulation (PSFS) is electrical stimulation via electrodes placed subcutaneously under the skin over the area of maximal pain. Similar to TENS. 

 

Chronic pain originating in peripheral nerves has very variable presentation, and often unclear etiology and as a result treatment is challenging. First-line pain management typically involves pharmacotherapy (NSAIDs, steroids, anti-depressants) and physical therapy. However, many patients do not achieve sufficient relief. Second and third-line options include therapeutic injections (epidural steroid injections, nerve blocks, trigger point injections), intrathecal drug pumps to deliver drugs directly to nerve centers and neurostimulation with electric pulses to override pain signals. Implantable peripheral nerve stimulation is being utilized for management of chronic pain of peripheral origin to treat upper/lower limb pain, entrapment syndromes, intercostal neuralgias and other peripheral injuries or diseases.

 

As with other types of implantable nerve stimulation, implantation of the peripheral nerve stimulator is typically a two-step process. Initially, the electrode is temporarily implanted allowing a trial period of stimulation typically up to a week. The temporary electrode is connected to an external power source that the patient controls. Once treatment effectiveness is confirmed, defined as at least 50% reduction in pain, the permanent placement of electrode are implanted which is connected either to an implanted pulse generator or the implanted electrode responds to a wireless system using an external radiofrequency transmitter.

 

Rationale

Evidence reviews assess the clinical evidence to determine whether the use of technology improves the net health outcome. Broadly defined, health outcomes are length of life, quality of life, and ability to function – including benefits and harms. Every clinical condition has specific outcomes that are important to patients and to managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcomes is a balance of benefits and harms.

 

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of a technology, 2 domains are examined: the relevance and the quality and credibility. To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative treatments at a comparable intensity. The quality and credibility of the evidence depend on the study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances non-randomized studies may be adequate.

 

Outcomes

The principal outcomes associated with the treatment of pain due to any cause includes: relief of pain, improved function and improved quality of life. Relief of pain can be a subjective outcome associated with a placebo effect (improvement of the patient’s condition simply because the person has the expectation that the treatment they are receiving might be helpful). Therefore, data from adequately powered, blinded, randomized controlled trials (RCTs) are required to determine if an implanted peripheral nerve stimulation system for chronic pain of peripheral nerve origin provides management changes and improves net health outcomes. Studies should also compare peripheral nerve stimulation with other neurostimulation such as spinal cord stimulation and alternative treatments with long term outcomes to assess safety and effectiveness.    

 

Systematic Reviews

There were no systematic reviews identified.

 

Case Series

The majority of the literature related to implantable peripheral nerve stimulation for various conditions (e.g. treatment of hemiplegic shoulder pain; peripheral neuropathic pain; intercostal neuralgia; back pain; neck pain; occipital neuralgia; postherpetic neuralgia; and trigeminal neuralgia/trigeminal neuropathic pain) is case series. While case series are appropriate for introducing novel interventions, they have inherent limitations. Results may be generalized, there are no controls, outcomes are not blinded, assessor bias cannot be ruled out, no comparative information to alternative treatments and no long term follow-up. These case series may show promising results, however, to be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative treatment(s) at a comparable intensity with long term follow-up to verify safety and efficacy.

 

Randomized Controlled Trials

In 2012, Silberstein et. al. published a randomized, controlled, double-blinded multicenter study on the safety and efficacy of peripheral nerve stimulation (PNS) of the occipital nerves for the management of chronic migraine in 157 patients. The patients were randomized to active treatment (n=105) or sham treatment (n=52). The primary endpoint was a difference in the percentage of responders (defined as patients that achieved a ≥50% reduction in mean daily visual analog scale scores) in each group at 12 weeks. There was not a significant difference in the percentage of responders in the Active compared with the Control group (95% lower confidence bound (LCB) of -0.06; p = 0.55). However, there was a significant difference in the percentage of patients that achieved a 30% reduction (p = 0.01). Importantly, compared with sham-treated patients, there were also significant differences in reduction of number of headache days (Active Group = 6.1, baseline = 22.4; Control Group = 3.0, baseline = 20.1; p = 0.008), migraine-related disability (p = 0.001) and direct reports of pain relief (p = 0.001). The most common adverse event was persistent implant site pain. The authors concluded, although this study failed to meet its primary endpoint, this is the first large scale study of (PNS) of the occipital nerves in chronic migraine patients that showed significant reductions in pain, headache days, and migraine-related disability. Additional controlled studies are warranted in this highly disabled patient population with a large unmet medical need.  

 

In 2016, Deer et. al. published a prospective, multicenter, randomized, double-blinded, partial crossover study to assess the safety and efficacy of the StimRouter neuromodulation system in the treatment of 94 patients with chronic pain of peripheral nerve origin. After IRB approval, patients were enrolled, implanted, and then followed for three months to assess efficacy and one year for safety based on Food and Drug Administration guidance. The patients were randomized to the treatment StimRouter group (45) or the control group (n=49).  The primary efficacy endpoint, three months after randomization to treatment, demonstrated that patients receiving active stimulation achieved a statistically significantly higher response rate of 38% vs. the 10% rate found in the Control group (p = 0.0048). Improvement in pain was statistically significant between the randomized groups, with the Treatment group achieving a mean pain reduction of 27.2% from Baseline to Month 3 compared to a 2.3% reduction in the Control group (p < 0.0001). During the partial crossover period, patients again demonstrated statistically significant improvement in pain relief with active stimulation compared to baseline. Further, the treatment group had significantly better improvement than the control group in secondary measures including but not limited to quality of life and satisfaction. Safety, assessed throughout the trial and with follow-up to one year, demonstrated no serious adverse events related to the device. All device-related adverse events were minor and self-limiting. However, the results need confirmation in additional randomized controlled trials (RCTs) with longer follow-up to draw conclusions. Studies should also compare StimRouter with other peripheral nerve stimulation systems such as spinal cord stimulation and alternative treatments. 

 

Ongoing Trial

A prospective, multi-center, single-arm study that will include 50 participants to assess StimRouter’s effectiveness for treating severe intractable chronic shoulder pain subsequent to stroke. The primary endpoint will be a clinically relevant pain reduction (30%) in pain score at 3 months after initiating stimulation in at least 50% of patients with no increase in pain medication. Expected completion September of 2019 (NCT03093935). This study will not provide the data needed to confirm efficacy and safety because it has no control group, and chronic pain waxes and wanes over time, pain is a subjective measure, and single-arm study design will have a high risk of bias so that results cannot be reliably attributed to the intervention. 

 

Nonrandomized Studies

In 2010, Deer et. al. published the results of prospective, single-center, open-label trial in which eight patients with carpal tunnel syndrome were evaluated for pain relief from the StimRouter. Primary endpoints were successful implantation near the target peripheral nerve and safety. All 8 patients were implanted temporarily at the median nerve in at least one arm and 2 patients were implanted bilaterally, with 10 implants total. Each implant was considered a separate "patient." For 5 days, all patients received 6 hours of daily transdermal electrical stimulation targeting the median nerve. Pain was measured at baseline, during implant, and after explant. Two patients experienced clinically meaningful (>or=30%) pain reduction throughout the entire 5-day treatment period. Apparent carryover effect in pain reduction also was observed after daily stimulation. After explant, pain returned to baseline, increasing 36.8% to 45.6% relative to average reduced pain with daily stimulation. No significant or unexpected adverse events occurred. The authors concluded temporary implant of the StimRouter device resulted in both pain reduction and reduced use of oral opioid pain medication during the 5 day stimulation period. The results suggest that permanent implant of the StimRouter System may be safe and effective for treating chronic peripheral neuoropathic pain. Limitation of this study includes small sample size and no long term follow-up after StimRouter explant.

 

Summary

Based on review of the peer reviewed medical literature the evidence is limited to two randomized controlled trials, nonrandomized trial, and case series that suggests implantable peripheral nerve stimulation is safe and works as intended to treat chronic pain of peripheral nerve origin. However, results need confirmation in additional randomized controlled trials (RCTs) with longer follow-up to draw conclusions on safety and efficacy. Further studies should also compare implantable peripheral nerve stimulation with other neuromostimulation therapy such as spinal cord stimulation and alternative treatments. There are no evidence based clinical practice guidelines that recommend the use of implantable peripheral nerve stimulation for the treatment of chronic pain of peripheral nerve origin. The evidence is insufficient to determine the effects of this technology on net health outcomes.      

 

Practice Guidelines and Position Statements

There are no evidence based clinical practice guidelines that recommend the use of implanted peripheral nerve stimulation for the treatment of pain of peripheral nerve origin.

 

Regulatory Status

In February 2015 the U.S. Food and Drug Administration (FDA) granted 510(k) marketing clearance for the StimRouter Neuromodulation System (Bioness, Inc., Valencia, CA). The StimRouter Neuromodulation System is indicated for pain management in adults who have severe intractable pain of peripheral nerve origin, as an adjunct to other modes of therapy (e.g. medications). The StimRouter is not intended to treat pain in the craniofacial region.

 

Patient Components

  • StimRouter Lead: The StimRouter Lead is flexible and approximately 15 cm (6 inches) in length. The lead had a stimulation end and a receiver end. The stimulation end is implanted near or at the targeted peripheral nerve and the receiver end is implanted new the skin surface. The receiver end receives the stimulation signal from the external pulse transmitter (EPT) and then send the signal through the lead to the stimulation end.
  • StimRouter External Pulse Transmitter (EPT): The StimRouter EPT generates the stimulation signal and transmits the signal through the StimRouter Electrode to the StimRouter Lead. The EPT snaps onto the StimRouter Electrode and responds to wireless commands from the Patient Programmer. 
  • StimRouter Electrode: The StimRouter Electrode features: 
    • Two gel pads that adhere the StimRouter Electrode to the skin. The gel pads also transmit the stimulation signal from the EPT to the receiver end of the lead. 
    • Two snaps for EPT placement.
    • Two tabs for removing the StimRouter Electrode from the skin. 
    • A liner to protect the gel pads on the back of the StimRouter Electrode. 
    • The StimRouter Electrode is disposable and can be reused by the same patient as long as the gel pads are intact and can fully adhere to the skin or for a maximum of four days of use. 
    • The typical lifespan of the StimRouter Electrode is two to four days depending on: 
      • The number of hours of use.
      • The number of times the StimRouter Electrode is adhered and removed from the skin. 
      • Hygiene and skin care in the area of StimRouter Electrode placement. 
  • Patient Programmer: The Patient Programmer communicates wirelessly with the EPT (external pulse transmitter). The Patient Programmer is used to turn stimulation on and off, to adjust the stimulation intensity and to select a stimulation program. 
     

 

In March 2016 the U.S. Food and Drug Administration (FDA) granted 510(k) marketing clearance for the StimQ Peripheral Nerve Stimulator (PNS) System (Stimwave LLC, Pompano Beach, FL). The StimQ Peripheral Nerve Stimulator (PNS) System is indicated for pain management in adults who have severe intractable chronic pain of peripheral nerve origin, as the sole mitigating agent, or as an adjunct to other modes of therapy used in a multidisciplinary approach. The therapy utilizes pulsed electrical current to create an electrical energy field that acts on peripheral nerves in the limbs and torso to alter transmission of pain signals to the brain. The StimQ PNS system is not intended to treat pain in the craniofacial region. The StimQ Trial Lead Kit is only used in conjunction with the StimQ Stimulator Receiver Kit. The trial devices are solely used for trial stimulation (no longer than 30 days) to determine efficacy before recommendation for a permanent (long term) device.

 

Device Description: 

  • The system is comprised of an implantable stimulator and an externally worn transmitter (StimQ Wearable Antenna Gear (SWAG)) to power the device. The system is implanted only following a successful trial period with the trial lead.   

 

In August 2017, the U.S. Food and Drug Administration (FDA) granted 510(k) marketing clearance for StimQ wireless peripheral nerve stimulator system. This device can be placed minimally-invasive, provides pain relief by delivering small pulses of energy to electrodes placed at a peripheral nerve enabling the brain to remap the pain signals. The implant is powered by a small external unit.  

 

Prior Approval:

Not required.

 

Policy:

See related medical policies

  • 07.01.61 Spinal Cord Stimulation 
  • 07.01.70 Peripheral Subcutaneous Field Stimulation (PSFS)

 

Implantable peripheral nerve stimulation to include temporary and permanent placement for the management of chronic pain of peripheral origin is investigational for all indications including but not limited to the following:

  • Chronic shoulder pain subsequent to stroke
  • Entrapment syndromes
  • Intercostal neuralgia
  • Low back pain
  • Neck pain
  • Neuropathic craniofacial pain
  • Occipital neuralgia
  • Painful nerve injuries
  • Painful peripheral neuropathies
  • Peripheral vascular disease neuropathy
  • Post herpetic neuralgia
  • Trigeminal neuralgia
  • Trigeminal neuropathic pain

 

Based on review of the peer reviewed medical literature the evidence is limited to two randomized controlled trials, nonrandomized trial, and case series that suggests implantable peripheral nerve stimulation is safe and works as intended to treat chronic pain of peripheral nerve origin. However, results need confirmation in additional randomized controlled trials (RCTs) with longer follow-up to draw conclusions on safety and efficacy. Further studies should also compare implantable peripheral nerve stimulation with other neuromodulation therapy such as spinal cord stimulation and alternative treatments. There are no evidence based clinical practice guidelines that recommend the use of implantable peripheral nerve stimulation for the treatment of chronic pain of peripheral nerve origin. The evidence is insufficient to determine the effects of this technology on net health outcomes.      

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes and / or diagnosis codes.

  • 64555 Percutaneous implantation of neurostimulator electrode array; peripheral nerve
  • 64575 Incision for implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
  • 64585 Revision or removal of peripheral neurostimulator electrode array
  • 64590 Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling
  • 64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver
  • 95970 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group(s), interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detectopm algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/transmitter, without programming
  • 95971 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group(s), interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detectopm algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional
  • 95972 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group(s), interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detectopm algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional
  • C1767 Generator neurostimulator (implantable) non-rechargeable
  • C1778 Lead, neurostimulator
  • C1787 Patient programmer, neurostimulator
  • C1816 Receiver and/or transmitter neurostimulator (implantable)
  • C1820 Generator, neurostimulator (implantable), non high-frequency with rechargeable battery and charging system
  • C1822 Generator, neurostimulator (implantable), high frequency, 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

 

Selected References:

  • ECRI. Product Brief StimRouter Neuromodulation System (Bioness, Inc.) for Treating Peripheral Nerve Pain. Published April 2018.
  • Centers for Medicare and Medicaid Services. National Coverage Determination (NCD) for Electrical Nerve Stimulators (160.7). 
  • Department of Health and Human Services Food and Drug Administration. StimQ Peripheral Nerve Stimulator (PNS) System
  • Stimwave. StimQ PNS System. 
  • Department of Health and Human Services Food and Drug Administration. StimRouter Neuromodulation System
  • StimRouter (Bioness Inc.) 
  • Picarelli H, Sterman-Neto H, Lima De-Oliveira et. al. Neuromodulation in treating complex regional pain syndrome: a critical review of the evidence. Journal of Neurology and Neuroscience 2017 Vol. 8: No. 1:173
  • Stidd DA, Wuollet AL, Bowden K, et. al. Peripheral nerve stimulation for trigeminal neuropathic pain. Pain Physician 2012 Jan-Feb 15(1):27-23. PMID 22270735
  • Alaa A, Abd-Elsayed, Grandhi R, et. al. Effective management of trigeminal neuralgia by neurostimulation. The Ochsner Journal 15:1935-195 2015. PMID 26130986
  • Kurlinsky S, Palmer SC, Arroliga MJ, et. al. Neuromodulation in postherpetic neuralgia: case reports and review of the literature. Pain Med 2018 Jun 1;19(6):1237-1244. PMID 29016994
  • Yakovlev AE and Peterson AT. Peripheral nerve stimulation in treatment of intractable postherpectic neuralgia. Neuromodulation 2007 Oct:10(4):373-5. PMID 22150898
  • Lerman IR, Chen JL, Hiller D, et. al. Novel high-frequency peripheral nerve stimulator treatment of refractory postherpectic neuralgia: a brief technical note. Neuromodulation 2015 Aug;18(6):487-93. PMID 25832898
  • Rauck R, Kapural L, Cohen S. et. al. Peripheral nerve stimulation for treatment of post-amputation pain – a case report. Pain Pract 2012 Nov 12(8): 649-655
  • Liu AJ, Ji HJ, Jioa YC, et. al. Peripheral nerve stimulation for occipital neuralgia. Chin Med J (Engl) 2015 Sep 20;128(18):2553-2554. PMID 26365981
  • Verrills P and Russo M. Peripheral nerve stimulation for back pain. Prog Neurol Surg 2015:29;127-38. PMID 26393502
  • Johnson RD, Green AL, and Aziz TZ. Implantation of an intercostal nerve stimulator for chronic abdominal pain. Ann R Coll Surg Engl 2010 Apr;92(3): el-e3.PMID 20412657
  • Slavin KV. Peripheral nerve stimulation for neurpathic pain. Neurotherapies 2008 Jan;5(1):100-106. PMID 18164488
  • Kozak J, Kobesova A, Steindler J, et. al. Peripheral nerve stimulation in intractable neuropathic pain. Neuro Endocrinol Lett 2011;32(3):226-33. PMID 21712779
  • Chan Jeon IK, Kim MS and Kim SH. Medial nerve stimulation in a patient with complex regional pain syndrome type II. J. Korean Neurosurg Soc 2009 Sep 46(3):273-276. PMID 19844632
  • Herschkowitz D and Kubias J. Wireless peripheral nerve stimulation for complex regional pain syndrome type I of the upper extremity: a case illustration introducing a novel technology. Scand J Pain 2018 Jul 26;18(3):555-560. PMID 29794269
  • Mobbs RJ, Nair S, Blum P. Peripheral nerve stimulation for the treatment of chronic pain. J Clin Neurosci 2007 Mar 14(3):216-21. PMID 17258129
  • Nguyen V, Bock W, Groves C, et. al. Fully implantable peripheral nerve stimulation for the treatment of hemiplegic shoulder pain: case report. Am J Phys Med Rehabil 2015 Feb;94(2)146-153. PMID 25251248
  • Gofeld M, Agur A. Peripheral nerve stimulation for chronic shoulder pain: a proof of concept anatomy study. Neuromodulation 2018 Apr;21(3):284-289. PMID 29314501
  • Deer TR, Levy RM, Rosenfeld EL. Prospective clinical study of a new implantable peripheral nerve stimulation device to treat chronic pain. Clin J Pain 2010 Jun;26(5):359-72. PMID 20473041
  • Wilson RD, Bennett ME, Nguyen VQC, et. al. Fully implantable peripheral nerve stimulation for hemiplegic shoulder pain: a multi-site case series with two year follow-up. Neuromodulation 2018 Apr;21(3):290-295. PMID 29164745
  • Deer T, Pope J, Benyamin R, et. al. Neuromodulation 2016 Jan;19(1):91-100. PMID 26799373
  • International Neuromodulation Society. Peripheral Nerve Stimulation. 
  • Slavin KV. Peripheral nerve stimulation for the treatment of neuropathic craniofacial pain. Acta Neurochir Suppl 2007;97(Pt1):115-20. PMID 1761633
  • Slavin KV, Colpan ME, Munawar N. et. al. Trigeminal and occipital peripheral nerve stimulation for craniofacial pain: a single institution experience and review of the literature. Neurosurg Focus 2006 Dec 15;21(6):E5. PMID 17341049
  • Silberstein SD, Dodick DW, Saper J, et. al. Safety and efficacy of peripheral nerve stimulation of the occipital nerves for the management of chronic migraine: results from a randomized, multicenter, double-blinded controlled study. Cephalalgia 2012 Dec;32(16):1165-79. PMID 23034698     

 

Policy History:

  • October 2018, New Policy

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.

 

*CPT® is a registered trademark of the American Medical Association.