TMPPM 2008 > Texas Medicaid Services > Physician > Procedures and Services

36.4.7 Neurostimulators

36.4.7.1 Central Nervous System Stimulators

The implantation of central nervous system electrical nerve stimulators is a benefit of the Texas Medicaid Program with documentation of medical necessity. It may be considered for reimbursement for the relief of chronic intractable pain. Conditions that may indicate chronic intractable pain include, but are not limited to the following:

•Amputation ghost pain:

•Cancer with bone metastasis (too numerous to list).

•Causalgia of upper/lower limb:

•Diagnosis codes 3544 and 35571.

•Herniated disc:

•Radiculitis:

•Diagnosis codes 09489, 7234, and 7292.

•Spinal stenosis:

•Spinal surgery, using the following procedure codes:

•Tic douloureux (Trigeminal neuralgia):

•Diagnosis codes 3501, 3502, and 05312.

The following types of central nervous system stimulators are benefits:

•Dorsal column (spinal cord) (2/F-63650, 2/8-63655, 2/F-63660, 2/F-63685, and 2/F-63688).

•Intracranial (2-61850, 2-61860, 2-61863, 2-61864, 2-61867, 2-61868, 2-61870, 2-61875, 2/8/F-61880, 2/F-61885, 2-61886, and 2/F-61888).

Documentation of the following must be submitted with claims for payment of the implantation of a dorsal column stimulator:

•Implantation of the stimulator is a last resort in a patient with chronic intractable pain. Other treatment modalities, including pharmacological, surgical, physical, and/or psychological therapies, have been tried and been shown to be unsatisfactory, unsuitable, or contraindicated for the patient.

•The patient has undergone careful screening, evaluation, and diagnosis by a multidisciplinary team before implantation. This screening should include psychological as well as physical evaluation.

•All the facilities, equipment, and professional and support personnel required for the proper diagnosis, treatment, training, and follow-up of the patient are available.

•Demonstration of pain relief with a temporarily implanted electrode preceded permanent implantation.

Separate payment for the device is not a benefit for the physician or hospital. It is included in the hospital or facility global payment group. Separate charges for the rental or purchase of the stimulator device (dorsal column, intracranial, deep brain, or vagal) are denied as not a benefit of the Texas Medicaid Program.

The implantation of intracranial neurostimulators is payable only for the following diagnoses and is subject to multiple surgery audit guidelines. When billing for intracranial neurostimulator implantation (2/F-61850, 2-61860, 2-61863, 2-61864, 2-61867, 2-61868, 2-61870, 2-61875, 2/8/F-61880, 2/F-61885, 2-61886, and 2/F-61888), the documentation required for dorsal column stimulators does not need to be submitted. When billing the following codes pertaining to the treatment of intractable pain with a dorsal column stimulator, prior authorization is not required: 2/F-63685 and 2/F-63688.

Documentation must be included in the client's records and is subject to retrospective review.

The following codes are payable through the Texas Medicaid Program without prior authorization for the electronic analysis of an implanted neurostimulator:

Payment will not be made for the implantation of central nervous system stimulators to treat motor function disorders such as multiple sclerosis. However, the implantation, revision, and removal of deep brain stimulators is a payable benefit for the treatment of intractable tremors because of diagnosis code 3320, or diagnosis code 3331.

However, if procedure codes 2/F-63685 or 2/F-63688 are billed for services provided in treating intractable seizures with a vagal nerve stimulator, they do require prior authorization.

Refer to: "Deep Brain Stimulators" for more information about prior authorization.