Neurostimulators and Neuromuscular Stimulators

27.1​Enrollment

To enroll in the CSHCN Services Program, providers of neurostimulators and neuromuscular stimulator devices and supplies must be actively enrolled in Texas Medicaid, have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services program enrollment process, and comply with all applicable state laws and requirements. Out-of-state providers of neurostimulator and neuromuscular stimulator devices and supplies must meet all these conditions, and be located in the United States, within 50 miles of the Texas state border, and approved by the Department of State Health Services (DSHS).

​Important:CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid.

By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in Title 26 Texas Administrative Code (TAC), but also with knowledge of the adopted Medicaid agency rules published in 1 TAC, Part 15, and specifically including the fraud and abuse provisions contained in Chapter 371.

CSHCN Services Program providers also are required to comply with all applicable laws, administrative rules, and policies that apply to their professions or to their facilities. Specifically, it is a violation of program rules when a provider fails to provide health-care services or items to recipients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC §371.1659 for Medicaid providers, which also applies to CSHCN Services Program providers as set forth in 26 TAC §351.6(b)(1). Accordingly, CSHCN Services Program providers can be subject to sanctions for failure to deliver, at all times, health-care items and services to recipients in full accordance with all applicable licensure and certification requirements. These include, without limitation, requirements related to documentation and record maintenance, such that a CSHCN Services Program provider can be subject to sanctions for failure to create and maintain all records required by his/her profession, as well as those required by the CSHCN Services Program and Texas Medicaid.

​Refer to: Section 2.1, “Provider Enrollment” in Chapter 2, “Provider Enrollment and Responsibilities” for more detailed information about CSHCN Services Program provider enrollment procedures.

27.2​Benefits, Limitations, and Authorization Requirements

As outlined in this chapter, neurostimulator procedures and the rental or purchase of devices and associated supplies, such as leads and form fitting garments, are a benefit of the CSHCN Services Program.

All procedures and related devices for the initial application or surgical implantation of neurostimulators and neuromuscular stimulators require prior authorization with documentation that supports medical necessity with one of the approved diagnoses listed in this section.

Prior authorization requests for neurostimulator and neuromuscular stimulator procedures and related devices may be considered for clients without one of the approved diagnoses and with documentation of medical conditions which will be reviewed by the Department of State Health Services (DSHS)-CSHCN Services Program Medical Director or a designee.

Neurostimulator and neuromuscular stimulator supplies, including leads and electrodes, do not require prior authorization.

Neurostimulator and neuromuscular stimulator supplies may be considered for reimbursement on appeal with documentation of a prior neurostimulator or neuromuscular stimulator procedure for clients with a history greater than five years or for those who did not receive a neurostimulator procedure through the CSHCN Services Program.

The revision or removal of implantable neurostimulators or neuromuscular stimulators does not require prior authorization; however, if the neurostimulator or neuromuscular stimulator device must be replaced, the device itself requires prior authorization with documentation that supports medical necessity with one of the approved diagnoses.

Prior authorization requests, including supporting documentation, must be submitted on the CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME) Form.

​Refer to: Section 4.4, “Prior Authorizations” in Chapter 4, “Prior Authorizations and Authorizations” for detailed information about prior authorization requirements.

27.2.1​Dorsal Column Neurostimulation (DCN)

DCN (procedure codes 63650, 63655, and 63685) involves the surgical implantation of neurostimulator electrodes within the dura mater or the percutaneous insertion of electrodes in the epidural space. The neurostimulation system stimulates pain-inhibiting nerve fibers, masking the sensation of pain with a tingling sensation (paresthesia).

DCN electrode implantation and the purchase of devices may be a benefit of the CSHCN Services Program when medically necessary for the treatment of chronic intractable pain. Permanent implantation will be considered when criteria are met, including completion of a one-month trial period demonstrating that an implantable device is needed.

Prior authorization for the implantation and purchase of DCN or ICN devices may be considered with one of the diagnosis codes listed in the table below:

Prior authorization for the implantation and purchase of DCN or ICN devices may be considered with a condition indicating chronic pain that is refractory to conventional therapy. Covered diagnosis codes are listed in the above table.

Documentation submitted with the request for permanent implantation and purchase of the DCN device must also demonstrate that:

•​Other treatment modalities, including pharmacological, surgical, physical, and/or psychological therapies, have been tried and were 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.

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

•​There has been demonstrated evidence of pain relief during a trial period of DCN with a temporarily implanted electrode or electrodes preceding the permanent implantation. The trial period must be a minimum of 30 days in duration.

​Note:The trial period including device and supplies is considered part of DCN procedure and will not be separately reimbursed.

Providers may request prior authorization for clients who do not meet the criteria listed for DCN or ICN in the table above. The provider must submit documentation of medical necessity with the request which will be reviewed by the DSHS-CSHCN Services Program Medical Director or a designee.

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 a DCN device:

27.2.2​Intracranial Neurostimulation (ICN)

ICN involves the stereotactic implantation of electrodes in the brain.

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 for the implantation and purchase of DCN or ICN devices may be considered with one of the diagnosis codes listed in the table below:

D

ICN procedures may be reimbursed using the following procedure codes:

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:

27.2.3​Neuromuscular Electrical Stimulation (NMES)

NMES (procedure code 64580) is used for the treatment of muscle atrophy or to enhance the functional activity of neurologically impaired clients as described in Section 27.2.3.1, “NMES for Muscle Atrophy” in this chapter and Section 27.2.3.2, “NMES for Walking in Clients with Spinal Cord Injury” in this chapter.

NMES requires prior authorization. The prior authorization request form must include documentation of a spinal cord injury or disuse atrophy that is refractory to conventional therapy.

The following procedure codes may be reimbursed for the rental or purchase of an NMES device:

The purchase of an NMES device is limited to once every 5 years.

27.2.3.1​NMES for Muscle Atrophy

NMES may be reimbursed when used to treat muscle disuse atrophy when brain, spinal cord, and peripheral nerve supply to the muscle is intact, as well as other non-neurological reasons. Examples of NMES treatment for non-neurological reasons include, but are not limited to, casting or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery until orthotic training begins.

27.2.3.2​NMES for Walking in Clients with Spinal Cord Injury

The type of NMES used to enhance an SCI client’s ability to walk is commonly referred to as functional electrical stimulation (FES). These devices are surface units that use electrical impulses to activate paralyzed or weak muscles in precise sequence. Reimbursement for NMES and FES is limited to SCI clients who have completed a training program consisting of at least 32 physical therapy sessions with the device over a period of 3 months.

The trial period of physical therapy will enable the physician treating the client for SCI to properly evaluate the client’s ability to use NMES and FES devices frequently and for the long term.

Physical therapy necessary to perform this training must be directly performed by the physical therapist as part of a one-on-one training program.

​Note:The goal of physical therapy must be to train SCI clients on the use of NMES and FES devices to achieve walking, not to reverse or retard muscle atrophy.

NMES and FES used for walking is a benefit for clients with SCI who have all of the following characteristics:

•​Intact lower motor unit (L1 and below; both muscle and peripheral nerve)

•​Muscle and joint stability for weight bearing at upper and lower extremities, and the balance and control necessary to maintain an upright support posture independently

•​Demonstrated brisk muscle contraction with NMES and have sensory perception electrical stimulation sufficient for muscle contraction

•​High motivation, commitment, and cognitive ability necessary to use such devices for walking

•​Ability to transfer independently and demonstrated independent standing tolerance for at least 3 minutes

•​Demonstrated hand and finger function to manipulate controls

•​At least 6-month recovery post spinal cord injury and restorative surgery

•​Hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis

•​Demonstrated a willingness to use the device in the long term

NMES and FES used for walking is not a benefit for clients with any of the following conditions:

•​Cardiac pacemakers

•​Severe scoliosis or severe osteoporosis

•​Skin disease or cancer at area of stimulation

•​Irreversible contracture

•​Autonomic dysflexia

27.2.4​Percutaneous Electrical Nerve Stimulation (PENS)

Implantation of PENS and electrodes is a benefit of the CSHCN Services Program. PENS (procedure codes 64553, 64555, 64590, 64596, 64597, and 64598) is a diagnostic service and may be covered for a 1-month trial to determine if an implantable device is needed. The medical necessity for such diagnostic services, which are furnished beyond the first month, must be documented, including the rationale for not considering an implantable device.

Because PENS is an office or outpatient therapy, the rental or purchase of the PENS devices, accessories, and supplies is not a benefit of the CSHCN Services Program.

Providers may request prior authorization for clients who do not meet the criteria listed for PENS in the table below. The provider must submit documentation of medical necessity with the request which will be reviewed by the DSHS-CSHCN Services Program Medical Director of a designee.

•​Treatment with TENS must have failed or have been contraindicated for the client.

•​The client must have a diagnosis indicating chronic pain that is refractory to conventional therapy. The covered diagnosis codes include the following:

D

All equipment and supplies for PENS are considered part of the service and are not reimbursed separately.

27.2.5​Sacral Nerve Stimulation (SNS)

SNS (procedure codes 64561, 64581, and 64590) is a benefit of the CSHCN Services Program. Prior authorization for the implantation and purchase of SNS devices may be considered with one of the following medical conditions:

•​Urinary incontinence secondary to urethral instability and/or detrusor muscle instability

•​Chronic voiding dysfunction

•​Non-obstructive urinary retention

•​Fecal Incontinence

The client’s medical record must include documentation of the following:

•​The urinary retention, urinary frequency, and urinary/fecal incontinence are refractory to conventional therapy (documented behavioral, pharmacological, or surgical corrective therapy).

•​The client is an appropriate surgical candidate such that implantation with anesthesia can occur.

Providers may request prior authorization for clients who do not meet the criteria listed above. The provider must submit documentation of medical necessity with the request that will be reviewed by the DSHS-CSHCN Services Program Medical Director or designee.

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 SNS device:

27.2.6​Transcutaneous Electrical Nerve Stimulation (TENS)

Transcutaneous electrical nerve stimulation (TENS) involves the attachment of a transcutaneous nerve stimulator to the surface of the skin over the peripheral nerve to be stimulated.

TENS rental or purchase of devices and conductive garments is a benefit of the CSHCN Services Program when medically necessary and prior authorized.

TENS for the treatment of overactive bladder (OAB) is limited to clients who have had the following:

•​An evaluation that was performed by an appropriate specialist, usually a urologist or urogynecologist, who determined that the client is a candidate for posterior tibial nerve stimulation (PTNS)

•​A medical record that includes the following documentation:

•​The client has been compliant with and has failed a trial of symptom-appropriate behavioral therapy of sufficient length to evaluate potential efficacy.

•​The client has been compliant with and has failed or been unable to tolerate a trial of at least two appropriate medications administered for four to eight weeks.

•​The client’s voiding diary shows continued findings of OAB.

•​The client has documented a willingness to attend in-office treatment sessions, to comply with behavioral therapies, and to continue to keep voiding diaries that include documentation of behavioral therapy compliance.

TENS (procedure code 64580) is a benefit of the CSHCN Services Program.

The following procedure codes may be reimbursed for the rental or purchase of a TENS device:

Procedure code E0733 is restricted to diagnosis code G500.

27.2.6.1​TENS Rental

The rental of a TENS device, accessories, and supplies may be a benefit and will be considered for prior authorization with documentation of a condition that indicates acute postoperative pain or chronic pain that is refractory to conventional therapy.

The rental of a TENS may be considered before purchase and is limited to a trial period of 1 month. One additional month’s rental of the TENS device may be considered with documentation of medical necessity. Supplies, such as lead wires and electrodes, are considered to be part of the rental and will not be reimbursed separately. Garments may be reimbursed during the rental period when medically necessary.

Rental reimbursement may not exceed the purchase price. Purchase is justified when the estimated duration of need multiplied by the rental rate exceeds the purchase price of the equipment.

Once it has been determined that electrical nerve stimulation should be continued for chronic pain and the client has been trained to use the stimulator, the CSHCN Services Program will no longer reimburse this therapy as an outpatient or office service.

27.2.6.2​TENS Purchase

The purchase of a TENS device, accessories, and supplies may be considered only after a 1-month trial period. In addition, the purchase of a TENS device will be considered for prior authorization with documentation of all of the following:

•​Acute postoperative pain or chronic pain that is refractory to conventional therapy

•​Successful test stimulation (during the rental or other therapeutic period) that shows improvement as measured by a demonstrated increase in range of motion

•​Improved ability to complete activities of daily living or perform activities outside the home

The purchase of a TENS device is limited to once every 5 years.

27.2.7​Pelvic Floor Stimulation

Prior authorization is not required for the purchase of a pelvic floor stimulator (procedure code E0740) when the criteria listed below are met:

•​Has a diagnosis of stress or urge incontinence.

•​Has completed a six-month trial of conservative treatment with no significant clinical improvement, such as Kegel exercises, behavior management, bladder training or medication.

Providers may request prior authorization for clients who do not meet the criteria listed above. The provider must submit documentation of medical necessity with the request, which will be reviewed by the DSHS-CSHCN Services Program Medical Director or a designee.

27.2.8​Vagal Nerve Stimulation (VNS)

The implantation, revision, programming, and removal of the VNS device are a benefit of the CSHCN Services Program for clients with medically intractable seizures who are not candidates for surgical intervention. VNS (procedure codes 61885, 61886, 64553, 64568, 64569, and 64570) may be reimbursed only when the diagnosis reflects medically refractory partial-onset seizures.

Prior authorization is required for the implantation and purchase of VNS devices. Prior authorization for the implantation and purchase of VNS devices may be considered for clients with partial onset intractable seizures when there is failure, contraindication or intolerance to all suitable medical and pharmacological management.

VNS is not a benefit in the following cases:

•​Treatment of clients with an absent left vagus nerve

•​Treatment of clients with depression

•​Treatment of clients with a progressively terminal illness or a medical disease that imparts a poor diagnosis

Prior Authorization is not required for procedure codes 64569 and 64570.

Incapacities that are due to intellectual disabilities (ID) or cerebral palsy may confound the assessment of benefits resulting from VNS. When a diagnosis of ID or cerebral palsy exists, the treating physician must document in the medical record how VNS will measurably benefit the client in spite of ID or cerebral palsy.

Providers may request prior authorization for clients who do not meet the criteria listed above. The provider must submit documentation of medical necessity with the request that will be reviewed by the DSHS-CSHCN Services Program Medical Director or designee.

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 a VNS device:

27.2.9​Hypoglossal Nerve Stimulators (HNS)

HNS (procedure code 64582) is a benefit of the CSHCN Services Program when medically necessary and prior authorized, for the treatment of obstructive sleep apnea (OSA) and seizures.

The revision or removal of an HNS may be reimbursed using procedure codes 64583 and 64584. Procedure codes 64583 and 64584 do not require prior authorization.

The surgical implantation of HNS and purchase of a device may be considered for prior authorization with documentation of the following:

•​Client has a documented diagnosis of obstructive OSA or seizures by a qualified health-care provider.

•​For OSA diagnosis, requests must include documentation that the client’s compliant use of continuous positive airway pressure (CPAP) for a minimum of 1 month (5 nights per week for at least 4 hours per night) has not been successful or is unable to be tolerated.

•​For OSA diagnosis, absence of complete concentric collapse at the soft palate level as seen on a drug-induced sleep endoscopy (DISE) procedure.

27.2.10​Electronic Analysis for Implantable Neurostimulators

The following procedure codes may be reimbursed for the electronic analysis of the implanted neurostimulator:

27.2.11​Electrocorticogram

Electrocorticogram (procedure code 95836) is a benefit of the CSHCN Services Program and may be reported only once for each 30 day period.

27.2.12​Revision or Removal of Implantable Neurostimulators

The revision or removal of implantable neurostimulators (DCN, ICN, SNS, or VNS) may be reimbursed as a surgery or assistant surgery using the following procedure codes:

Ambulatory surgical centers may be reimbursed using the procedure codes listed in the table above, except for procedure code 61781. These procedure codes are not a benefit for ambulatory surgical centers.

Supplies for the implantable devices listed in this policy may be reimbursed for clients with a purchased device and a claims history of a prior neurostimulator or neuromuscular stimulator implantation within the last 5 years.

​Note:Providers must maintain documentation in the client’s medical record that a device has been purchased. Additional documentation such as the purchase date, serial number, and purchasing entity of the initial device may be required.

Supplies for implantable devices as listed in this policy may be considered for reimbursement on appeal with documentation of a prior neurostimulator or neuromuscular stimulator implantation procedure for clients with a history greater than 5 years or for those who did not receive a neurostimulator procedure through CSHCN Services Program.

The revision or removal of a peripheral neurostimulator used in PENS therapy may be reimbursed using procedure code 64595.

27.2.13​Implantable Neurstimulators and Neuromuscular Stimulators

Implantable neurostimulator services may be reimbursed using procedure code 64575. Implantable supply (procedure codes A4290, L8680, and L8696) will be denied if they are not submitted for clients with a purchased device and a claims history within 5 years of related procedure code 64575 by any provider.

One of the following implantable neurostimulator device procedure codes must be billed on the same date of service as related procedure code 64575 by any provider.

Neurostimulator supplies, including leads and electrodes, may be benefits for clients with a purchased device and a claims history of a prior neurostimulator or neuromuscular stimulator procedure within the last five years.

Providers must maintain documentation in the client’s medical record that a device has been purchased. Additional documentation such as the purchase date, serial number, and purchasing entity of the initial device may be required.

27.2.13.1​NMES and TENS Garments

The prior authorization request form for the purchase of the NMES and TENS conductive garments must include supporting documentation that shows:

•​The garment has been prescribed by a physician for use in delivering covered NMES and TENS treatment.

•​The client has successfully completed a 1-month trial period.

•​The conductive garment is necessary for one of the medical indications outlined below:

•​The client cannot manage without the conductive garment because there is such a large area or so many sites to be stimulated and the stimulation would have to be delivered so frequently that it is not feasible to use conventional electrodes, adhesive tapes, and lead wires.

•​The client cannot manage without the conductive garment for the treatment of chronic intractable pain because the areas or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes, and lead wires.

•​The client has a documented medical condition, such as a skin problem, that precludes the application of conventional electrodes, adhesive tapes, and lead wires.

The rental of the NMES and TENS garment is not a benefit during the trial rental period unless the client has a documented skin problem prior to the start of the trial period; and DSHS or its designee is satisfied that the use of such an item is medically necessary for the client.

27.2.13.2​NMES and TENS Supplies

NMES and TENS supplies may be reimbursed with procedure code A4541, A4556, A4557, or A4595.

Supplies for purchased devices are limited as follows:

•​If additional electrodes are required, procedure code A4556 may be reimbursed at a maximum of 15 per month.

•​If additional lead wires are required, procedure code A4557 may be reimbursed at a maximum of two per month.

•​Procedure codes A4541 and A4595 are limited to one per month.

•​Procedure code A4541 is restricted to diagnosis code G500.

The purchase of supplies for NMES/TENS may only be considered for reimbursement for clients with a purchased device and a claims history of a NMES/TENS procedure within the last 5 years.

The physician or physical therapist providing the services may furnish the equipment necessary for assessment. When the physician or physical therapist advises the client to rent the TENS from a supplier during the trial period rather than supplying it, program payment may be made for the rental of the TENS as well as for the services of the physician or physical therapist who is evaluating its use. However, the combined program payment made for the physician’s or physical therapist’s services and rental of the stimulator from a supplier should not exceed the amount which would be a benefit for the total service, including the stimulator, furnished by the physician or physical therapist alone.

27.3​Claims Information

To avoid claim denials, providers billing as a group must use the performing National Provider Identifier (NPI) number on their claims.

Neurostimulator devices and supplies must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms.

When completing a CMS-1500 paper claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements.

All claims and authorization requests submitted by CSHCN Services Program home health durable medical equipment (DME) providers must be submitted with benefit code DM3.

The Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes included in policy are subject to National Correct Coding Initiative (NCCI) relationships. Exceptions to NCCI code relationships that may be noted in CSHCN Services Program medical policy are no longer valid. Providers should refer to the Centers for Medicare & Medicaid Services (CMS) NCCI web page for correct coding guidelines and specific applicable code combinations. In instances when CSHCN Services Program medical policy quantity limitations are more restrictive than NCCI Medically Unlikely Edits (MUE) guidance, medical policy prevails.

​Refer to: Chapter 41, “TMHP Electronic Data Interchange (EDI)” for information about electronic claims submissions.

Chapter 5, “Claims Filing, Third-Party Resources, and Reimbursement” for general information about claims filing.

Section 5.7.2.4, “CMS-1500 Paper Claim Form Instructions” in Chapter 5, “Claims Filing, Third-Party Resources, and Reimbursement” for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank.

27.4​Reimbursement

Neuromuscular devices and the implantation codes must be billed on the same day by any provider.

Physicians may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid.

Inpatient hospitals may be reimbursed at 80 percent of the All Patient Refined Diagnosis Related Groups (APR-DRG) payment for all CSHCN serivces.

Outpatient hospital services are reimbursed at 72 percent of the billed amount multiplied by the hospital’s Medicaid interim rate.

DME suppliers may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid.

Advanced practice registered nurses (APRNs) and physician assistants (PAs) may be reimbursed the lower of the billed amount or 92 percent of the amount allowed by Texas Medicaid for the same service performed by a physician.

For fee information, providers can refer to the Online Fee Lookup (OFL) on the TMHP website at www.tmhp.com.

The CSHCN Services Program implemented rate reductions for certain services. The OFL includes a column titled “Adjusted Fee” to display the individual fees with all percentage reductions applied. Additional information about rate changes is available on the TMHP website at www.tmhp.com/resources/rate-and-code-updates/rate-changes.

​Note:Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column.

27.5​TMHP-CSHCN Services Program Contact Center

The TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 is available Monday through Friday from 7 a.m. to 7 p.m., Central Time, and is the main point of contact for the CSHCN Services Program provider community.