CurrentAlliance HealthPolicy 1A-25

NC Medicaid Spinal Cord Stimulation (SCS)

Defines NC Medicaid coverage, prior approval, provider, billing, and coding requirements for spinal cord stimulation (trial and permanent) for beneficiaries in North Carolina.

Policy Summary

PayerAlliance Health

PolicyNC Medicaid Spinal Cord Stimulation (SCS)

Policy CodePolicy 1A-25

Change TypeNo material change

Effective DateAugust 15, 2023

Next Review DateN/A

Key ActionSubmit a prior approval request with all supporting health records to the DHHS Utilization Review Contractor demonstrating the beneficiary meets the clinical criteria in Subsection 3.2.1.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PA requiredPrior authorization requirement

63650-63688, 95970-95973Procedure codes referenced

Inpatient/Outpatient/OfficeAllowed places of service

1/unitBilling unit rule

Coverage Criteria for Spinal Cord Stimulation

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Prior approval submission: Provider must submit the prior approval request to the Department of Health and Human Services (DHHS) Utilization Review Contractor.

Supporting documentation: Provider must submit all health records and any other records that support the beneficiary has met the specific criteria in Subsection 3.2.1 of this policy.

Subsection 3.2.1 contains the clinical medical necessity criteria (not present in this partial document).

Procedure and Billing Codes

Medicaid-covered procedure codes for spinal neurostimulatorsCPTCovered

63650	Prior Approval Required? = Yes.
63655	Prior Approval Required? = Yes.
63685	Prior Approval Required? = Yes.
63661	Prior Approval Required? = No.
63662	Prior Approval Required? = No.
63663	Prior Approval Required? = No.
63664	Prior Approval Required? = No.
63688	Prior Approval Required? = No.
95970	Prior Approval Required? = No.
95971	Prior Approval Required? = No.

1–10 of 12

1/2

CPT codes allowed in office settingCPTCovered

95970	May be billed in the office setting.
95971	May be billed in the office setting.
95972	May be billed in the office setting.
95973	May be billed in the office setting.

inv-06: Billing units — One unit per date of service for the above procedure codes

Billing unit ruleOne billing unit per date of service for the listed SCS procedure codes

Unit determinationBilling unit is determined by the procedure code reported on the claim

Multiple services same dayDo not bill more than one unit per date of service for the same procedure code unless code definition allows multiple units

inv-15: Coding and claims guidance — providers must use current ICD-10-CM, CPT, HCPCS, and UB-04 specifications

Use current code setsProviders shall use the Current Procedural Terminology (CPT), HCPCS, ICD-10-CM, and UB-04 Data Specifications Manual in effect at the time of service

Highest specificityReport the most specific billing code that accurately and completely describes the procedure, product, or service

Follow NCTracks guidanceComply with NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, and fee schedules for claims submission

inv-17: Listed SCS procedure codes — One billing unit per date of service

Billing units for listed SCS CPTsOne billing unit per date of service for each listed SCS procedure code (e.g., 63650, 63655, 63661–63664, 63685, 63688, 95970–95973)

Codes listedPolicy lists CPT codes: 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, 95970, 95971, 95972, 95973

Prior approval indicatorsSome listed codes have prior approval requirements (see coding section for specific codes)

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior approval is required for both the trial and permanent spinal cord stimulation (SCS) procedures. Submit a prior approval request to the payer when performing trial or permanent SCS for codes flagged below.

Affected CPTs: 63650, 63655 (PA required)
Note: Claims for CPTs flagged as prior approval required may be denied if PA is not obtained.

Denial Risk

Prior Approval Requirement and Denial Risk

Claims submitted for CPT codes that are flagged as requiring prior approval (see code list) may be denied if prior approval is not obtained and proper documentation is not submitted.

Denial risk applies to CPTs listed as "Prior Approval Required? = Yes" (e.g., 63650, 63655).

Billing Rule

Place of Service and Office Billing for Select CPTs

95970–95973 may be reported when services are furnished in the office setting in addition to inpatient and outpatient settings. Ensure place of service is correctly reported on the claim.

Allowed places of service: Inpatient, Outpatient. 95970–95973: Inpatient, Outpatient, and Office.

Documentation Required

Required Documentation for Prior Approval

Submit the prior approval request and include all supporting health records demonstrating the beneficiary meets the policy criteria. Include clinical notes, diagnostic studies, prior conservative therapy documentation, and any other records referenced in the PA request.

Send the PA request and all supporting health records to the DHHS Utilization Review Contractor.
Include documentation showing criteria in Subsection 3.2.1 are met.

Documentation Required

Billing and Reimbursement Documentation

Report the most specific CPT/HCPCS code that accurately describes the service. Bill usual and customary charges. Use the applicable coding manuals in effect at the time of service. For reimbursement rates, refer to the payer's published schedule.

Report the most specific CPT or HCPCS code available; use unlisted codes only if no specific code exists.
Bill usual and customary charges; refer to the payer rate schedule for fee amounts: https://medicaid.ncdhhs.gov/.

Billing Rule

Unit Billing Mismatch

Billing more than one unit per date of service for these procedure codes may trigger review or denial if inconsistent with the code definition. Providers may generally bill one unit per date of service for the listed procedure codes unless the code description supports multiple units.

Default billing: one unit per date of service for the listed procedure codes.
Multiple units on the same date may be denied if inconsistent with the procedure definition.

Note

Specific Provider Actions

Specific: None Apply.

Imaging and Diagnostic Requirements

Note

No imaging requirements in this section — see clinical criteria

No imaging requirements are specified in this portion of the policy; providers must refer to the clinical medical necessity criteria in Subsection 3.2.1 for any imaging expectations when documenting eligibility for SCS.

Imaging expectations, if required, are detailed in Subsection 3.2.1 (not included here).

Definitions and Claims Guidance

inv-15: Coding and claims guidance (repeated placement) — use current code sets and highest specificity at time of service

Use current coding editionsProviders shall use current ICD-10-CM, CPT, HCPCS, and UB-04 specifications and report codes to the highest level of specificity in effect at the time of service

Unlisted proceduresIf no specific CPT or HCPCS code exists, report the procedure using the appropriate unlisted procedure or service code

Claims complianceFollow NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, and NC Medicaid clinical coverage policies for submission and reimbursement

Frequency and Unit Limits