63685
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
5.06
Facility
$318.64
Non-Facility
$318.64
Documentation Required
- Appropriate medical documentation supporting need for repeat trial or exceptions (e.g., technical limitations, different modality/new technology) must be submitted for appeals.
- Providers must verify applicable CCI edits and correct coding guidelines prior to billing Medicare; this article does not replace CCI guidance.
- The clinical record must document the elements leading to the diagnosis and the conservative therapies tried before electing SCS.
- Documentation must be available on request of patient selection criteria, radiologic imaging demonstrating proper lead placement, and medical necessity of trials, particularly for providers under post-payment review.
Key Coverage Criteria
- Placement of up to 2 spinal cord stimulator leads or a maximum of 16 contacts is reimbursable.
- Up to 2 SCS trials per anatomic spinal region per patient per lifetime are reimbursable, with exceptions for technical limitations or use of different stimulation modalities/new technology.
- CPT 63650 (temporary/percutaneous SCS trial) is reimbursable in office, ASC, outpatient hospital, or hospital settings.
- Permanent spinal cord stimulator implantation (CPT 63655) is reimbursable once per patient per lifetime and must be performed in an ASC, outpatient hospital, or hospital.
- Percutaneous placement of permanent neurostimulator arrays (using CPT 63650) may be covered more often when performed in ASC, outpatient hospital, or hospital settings.
- Spinal cord stimulation (SCS) is covered for chronic pain when the clinical record documents the diagnosis and prior conservative therapies tried before the decision to use SCS.
20 Active Policies
AMBETTER-CP.MP.117 — Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation
AETNA-CPB-0194 — Spinal Cord Stimulation
AETNA-CPB-0362 — Spasticity Management
AETNA-CPB-0707 — Headaches: Invasive Procedures
AETNA-CPB-0754 — Chronic Pelvic Pain, Endometriosis, and Other Indications: Selected Treatments
Related Codes
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