9.2.43.7

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:

•	Post-amputation “ghost” pain

•	Cancer with bone metastasis

•	Causalgia of upper/lower limb

•	Herniated disc

•	Radiculitis

•	Spinal stenosis

•	Spinal surgery

•	Tic douloureux (trigeminal neuralgia)

9.2.43.7.1

Prior Authorization for Dorsal Column Neurostimulators

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.

•	The client has undergone careful screening, evaluation, and diagnosis by a multidisciplinary team prior to implantation.

•	There has been evidence of pain relief during a trial period for DCN with a temporarily implanted electrode or electrodes preceding the permanent implantation.

Note:

A trial period including device and supplies is considered part of DCN procedures and will not be separately reimbursed.

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