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25.2.3 Intracranial Neurostimulation (ICN)
ICN involves the stereotactic implantation of electrodes in the brain and is a benefit of the CSHCN Services Program when medically necessary.
The surgical implantation, revision, and removal of intracranial deep-brain stimulators (DBS) are a benefit for the relief of chronic intractable pain when more conservative methods, such as TENS, PENS, or pharmacological management, have failed or were contraindicated.
ICN is also covered for the treatment of intractable tremors due to idiopathic Parkinson's disease or essential tremors.
Prior authorization is not required for the implantation and purchase of a device for ICN with the following diagnosis codes:
ICN procedures may be reimbursed as a surgery or assistant surgery using the following procedure codes:
Ambulatory surgical centers may be reimbursed using the ICN procedure codes in the table above.
Only one similar device code may be reimbursed per date of service for any provider. The following procedure codes may be reimbursed for the purchase of an ICN device:
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