CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Peripheral Subcutaneous Field Stimulation (PSFS) — Coverage Criteria

Policy governing coverage and medical necessity for peripheral subcutaneous field stimulation (also called peripheral nerve field or target field stimulation) for chronic neuropathic pain for Blue Cross Blue Shield - Rhode Island products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPeripheral Subcutaneous Field Stimulation (PSFS) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2017

Next Review Date

Key ActionDo not submit prior authorization; prior authorization is not required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not medically necessaryCommercial coverage stance

Not coveredMedicare coverage stance

No PAAuthorization

Percutaneous ≥50%Trial requirement

CPT 64999Billing guidance

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Coverage Determinations and Policy Scope

Coverage determinations

Coverage determinations by product

BlueCHiP for Medicare - Not covered: Peripheral subcutaneous field stimulation (PSFS) is considered not covered as the evidence is insufficient to determine the effects of the technology on health outcomes.

Commercial Products - Not medically necessary: Peripheral subcutaneous field stimulation (PSFS) is considered not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.

General procedural practice statement: Permanent implantation is typically preceded by a percutaneous stimulation trial with at least 50% pain reduction; however, currently there is no consensus regarding indications for PSFS.>=50% pain reduction for trial

Descriptive practice statement from background, not a coverage approval condition

Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine whether peripheral subcutaneous field stimulation (PSFS) is a covered service or considered not medically necessary/not covered for a specific member.

For Commercial products, peripheral subcutaneous field stimulation (PSFS) is considered not medically necessary. The evidence is insufficient to determine the effects of PSFS on health outcomes, and therefore it is not supported as medically necessary for these products.

Billing and Coding Guidance

Billing guidance (no specific CPT code)CPT

64999

Unlisted procedure, nervous system

Percutaneous stimulation trial response

Trial response threshold>= 50% reduction in pain during a percutaneous stimulation trial

Purpose of trialPercutaneous trial is performed prior to permanent implantation to demonstrate adequate pain relief

Role in care pathwayUsed for patients with chronic neuropathic pain refractory to other modalities

Candidate selection considerationsTrial candidates may have a clearly defined focal area of neuropathic or combined somatic/neuropathic pain and failure of conservative treatments

Documentation implicationTrial response is a descriptive practice statement in background; not a coverage approval condition in this policy

Provider Requirements and Administrative Actions

Prior Authorization

Prior authorization is not required.

Note

Stimulation Trial Practice

A percutaneous stimulation trial with at least 50% pain reduction is typically performed before permanent implantation. Criteria for a PSFS trial may include a clearly defined, discrete focal area of pain with a neuropathic or combined somatic/neuropathic pain component (e.g., burning, increased sensitivity) and failure to respond to other conservative treatments including medications, psychological therapies, physical therapies, surgery, and pain management programs.

Billing Rule

Billing/Documentation

There is no specific CPT code for this treatment. Report using unlisted CPT code 64999 (Unlisted procedure, nervous system).

Use CPT 64999 for billing — Unlisted procedure, nervous system.

Denial Risk

Coverage-based Denial Risk

Coverage may be denied. For BlueCHiP for Medicare, PSFS is considered not covered. For Commercial products, PSFS is considered not medically necessary. Denials may occur because the evidence is insufficient to determine the effects of the technology on health outcomes.

BlueCHiP for Medicare: not covered.
Commercial Products: not medically necessary.

Clinical Background

Background: Peripheral subcutaneous field stimulation (PSFS) is a neuromodulation technique in which leads are placed subcutaneously in the area of maximal pain to stimulate cutaneous afferents or dermatomal distributions for chronic neuropathic pain. PSFS is commonly considered when pain is refractory to medications and nonpharmacologic therapies; permanent implantation is typically preceded by a percutaneous stimulation trial with demonstration of at least 50% pain reduction. The mechanism of benefit remains uncertain and potential complications include lead migration, breakage, and infection. Coverage and applicability may vary by contract, so consult the member’s benefit documents for specific coverage determinations.

Key Definitions

Definition: Peripheral subcutaneous field stimulation (PSFS)

DefinitionPSFS is neuromodulation with subcutaneous lead placement in the area of maximal pain to stimulate affected cutaneous afferents or dermatomal distribution

Alternate namesAlso called peripheral nerve field stimulation or target field stimulation

MechanismMechanism is uncertain; proposed actions include stimulation of cutaneous afferents, modulation of nerve fiber activity, and central effects

Typical useIntended to treat chronic neuropathic pain, often after failure of medications and nonpharmacologic therapies

ComplicationsReported complications include lead migration or breakage and infection of the lead or neurostimulator

Conservative Therapy Requirements for Candidate Selection

Conservative treatment requirements

Failure of conservative treatments described as part of candidate selection for trial

Candidate selection for percutaneous PSFS trial: The patient has a clearly defined, discrete focal area of pain with a neuropathic or combined somatic/neuropathic pain component (eg, burning and increased sensitivity).

Prior conservative treatment failure: Failure to respond to other conservative treatments, which may include medications, psychological therapies, physical therapies, surgery, and participation in pain management programs.

This requirement describes typical candidate selection for a trial and is not an authorization criterion for permanent implantation under this policy.

Explicit Non‑Coverage Statements

Not covered: PSFS is explicitly not covered under BlueCHiP for Medicare and is considered not medically necessary for Commercial products due to insufficient evidence of clinical benefit. Claims for PSFS may be denied on the basis of not covered (Medicare) or not medically necessary (Commercial) determinations; verify coverage against the member’s Benefit Booklet/Evidence of Coverage/Subscriber Agreement.