SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

This policy addresses implantable peripheral nerve stimulation devices for pain, specifically the ReActiv8 Implantable Neurostimulation System. Coverage is provided only when all criteria are met: adult age (≥18), diagnosis of lumbar multifidus muscle dysfunction, chronic low back pain >6 months that is non-radicular and non-neuropathic, and documentation that other potential sources of pain have been ruled out. All other uses of implantable peripheral nerve stimulation devices, or when these criteria are not met, are considered investigational and not medically necessary.

"The ReActiv8 Implantable Neurostimulation System is consideredmedically necessarywhenallof the following criteria are met:"

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