95972
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.80
Facility
$35.07
Non-Facility
$59.79
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.
- Claims must be supported by medical record documentation demonstrating that the service meets the LCD L39543 indications and limitations and general CMS medical necessity requirements.
- Medical record must contain documented history and careful screening, including multidisciplinary evaluation and both psychological and physical assessments, available on request.
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.
- Services for sacral nerve stimulation are covered only when they meet all indications specified in Local Coverage Determination L39543 for treatment of urinary and/or fecal incontinence.
14 Active Policies
AMBETTER-CP.MP.137 — Fecal Incontinence Treatments
AMBETTER-CP.MP.117 — Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation
AETNA-CPB-0707 — Headaches: Invasive Procedures
A56876 — Billing and Coding: Spinal Cord Stimulators for Chronic Pain
A59332 — Billing and Coding: Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence
Related Codes
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