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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.43 Neurostimulators : Dorsal Column Neurostimulator (DCN)
DCN involves the surgical implantation of neurostimulator electrodes within the dura mater (endodural) or the percutaneous insertion of electrodes in the epidural space. The neurostimulator system stimulates pain-inhibiting nerve fibers, masking the sensation of pain with a tingling sensation (paresthesia).
DCN implantation may be reimbursed using procedure codes 61783, 63650, 63655, or 63685.
Conditions that may indicate chronic intractable pain include, but are not limited to, the following:
DCN electrode implantation and the purchase of devices is a benefit of Texas Medicaid when medically necessary and prior authorized.
The surgical implantation of DCN device may be considered for prior authorization for clients who have chronic intractable pain with documentation that indicates the following:
Other treatment modalities, including pharmacological, surgical, physical, and/or psychological therapies, have been tried and shown to be unsatisfactory, unsuitable, or contraindicated for the client.
All the facilities, equipment, and professional and support personnel required for the proper diagnosis, treatment, training, and the client’s follow-up are available.

Texas Medicaid & Healthcare Partnership
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