ModifiedCentenePolicy CP.MP.117

Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation

Defines coverage stance and medical necessity criteria for spinal cord stimulation (SCS) and states insufficient evidence for peripheral nerve stimulation (PNS), peripheral nerve field stimulation (PNFS), percutaneous electrical nerve stimulation (PENS), and percutaneous electrical nerve field stimulation (PENFS); applies to Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicySpinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation

Policy CodePolicy CP.MP.117

Change TypeMaterial updates: PENFS/PENS deemed insufficient evidencePENS criteria removedcoding updates

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with documentation showing ≥6 months of failed conservative therapy and a documented SCS trial (≥3 days) with >50% pain reduction and functional improvement.

SourceLink

POLICY UPDATE CHANGES

Added criteria stating there is insufficient evidence to support the efficacy of PENFS/PENS for any indication, including irritable bowel syndrome (IBS), and added CPT code 0720T as not covered.

Removed medically necessary criteria for PENS and removed several 'for a minimum of 60 days prior to request, as confirmed by lab testing' requirements from multiple criteria sections.

Added CPT codes 64596, 64597, 64598 and HCPCS code L8678 to supporting/code lists.

SCSSCS medically necessary

InsufficientPNS/PNFS/PENS/PENFS stance

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Coverage Criteria and Medical Necessity

PENFS/PENS — Insufficient Evidence

It is the policy of health plans affiliated with Centene Corporation that there is insufficient evidence to support the efficacy of percutaneous electrical nerve stimulation (PENS) and percutaneous electrical nerve field stimulation (PENFS) for any indication.

A. Percutaneous electrical nerve stimulation (PENS) and percutaneous electrical nerve field stimulation (PENFS) are considered investigational/experimental and not medically necessary for all indications due to insufficient evidence of efficacy.

B. PENFS has been specifically assessed for indications including irritable bowel syndrome (IBS) and evidence is insufficient to support its use for IBS or other conditions.

C. Prior medically necessary criteria that previously existed for PENS have been removed; PENS is now categorized with PENFS as lacking sufficient evidence to support efficacy.

D. CPT code 0720T (Percutaneous electrical nerve field stimulation, cranial nerves, without implantation) and other codes associated with PENS/PENFS are considered not to support coverage criteria (see Coding section).

Coding and Procedure Codes

CPT Codes That Do Not Support Coverage CriteriaCPTNot Covered

0720T

Percutaneous electrical nerve field stimulation, cranial nerves, without implantation

CPT Codes That Do Not Support Coverage Criteria (duplicate)CPTNot Covered

0720T

Percutaneous electrical nerve field stimulation, cranial nerves, without implantation

CPT Codes That Support Coverage CriteriaCPTCovered

63650	Percutaneous implantation of neurostimulator electrode array, epidural.
63655	Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural.
63685	Insertion or replacement of spinal neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver.
64555	Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve).
64575	Open implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve).
64585	Revision or removal of peripheral neurostimulator electrode array.
64590	Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver.
64595	Revision or removal of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, with detachable connection to electrode array.
64596	Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; initial electrode array.
64597	Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; each additional electrode array (List separately in addition to code for primary procedure).

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HCPCS Codes That Support Coverage CriteriaHCPCSCovered

L8678	Electrical stimulator supplies (external) for use with implantable neurostimulator, per month.
L8679	Implantable neurostimulator, pulse generator, any type.
L8680	Implantable neurostimulator electrode, each.
L8681	Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only.
L8682	Implantable neurostimulator radiofrequency receiver.
L8683	Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver.
L8685	Implantable neurostimulator pulse generator, single array, rechargeable includes extension.
L8686	Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension.
L8687	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension.
L8688	Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension.

SCS trial duration (inv-17)

SCS trial durationDocumented trial duration of ≥ 3 days prior to permanent SCS placement.

Trial requirement contextApplies to permanent placement following a successful SCS trial per permanent placement criteria.

DocumentationTrial duration must be recorded in clinical documentation submitted for prior authorization and permanent implant consideration.

Required pain reduction during SCS trial (inv-18)

Required pain reduction> 50% pain reduction from the SCS trial associated with functional improvement is required for permanent placement.

Functional improvement

Provider Requirements, Prior Authorization, and Billing Impacts

Prior Authorization

Prior Authorization Required

Prior authorization required for SCS and select neurostimulator procedures. Providers must obtain prior authorization for spinal cord stimulation (SCS) trials and permanent implant procedures per plan requirements. Requests for procedures should include required documentation to support medical necessity to avoid delays or denials.

Affected CPT/HCPCS include: 63650, 63655, 63685, 64555, 64575, 64585, 64590, 64595, 64596, 64597, 64598, 64999, 95970; HCPCS: L8678–L8688
Use the most up-to-date CPT/HCPCS coding guidance when submitting requests

Denial Risk

Denial Risk — CPT 0720T

Denial risk for CPT 0720T. Requests coded with CPT 0720T (Percutaneous electrical nerve field stimulation, cranial nerves, without implantation) do not support coverage criteria and may be denied.

CPT 0720T listed as not supported for coverage in this policy

Background and Scope

Neuromodulation therapies covered by this policy encompass stimulation of peripheral nerves, nerve fields, and the dorsal columns. Spinal cord stimulation (SCS) is addressed with defined medical necessity criteria and trial-to-permanent requirements for select indications (e.g., failed back surgery syndrome, CRPS, ischemic limb pain, refractory angina). In contrast, peripheral-targeted modalities such as PNS, PNFS, PENS, and PENFS — and dorsal root ganglion (DRG) stimulation — are designated as having limited or insufficient evidence; recent updates explicitly reclassified PENFS and PENS as unsupported for any indication. This policy applies to Centene-affiliated health plans and is intended to guide prior authorization, documentation, and coverage decisions for neuromodulation procedures.

Definitions

PNS / PNFS / PENS / PENFS definitions (inv-30)

PNS definitionPeripheral nerve stimulation (PNS) uses leads placed adjacent or parallel to an affected peripheral nerve to decrease chronic or acute pain.

PNFS definitionPeripheral nerve field stimulation (PNFS) places leads in the painful region to stimulate smaller peripheral nerves and nerve endings when a single nerve does not clearly service the area.

PENS/PENFS distinctionPercutaneous electrical nerve stimulation (PENS) uses fine needles as electrodes placed in soft tissues or muscles at dermatomal levels; PENFS is a variation targeting a general pain area rather than a specific nerve.

SCS / DCS definitions (inv-31)

SCS / DCS definitionSpinal cord stimulation (SCS), also called dorsal column stimulator (DCS), delivers electrical stimulation to the dorsal aspect of the spinal cord to interfere with conduction of pain impulses.

Conservative Treatment and Prior Therapy Requirements

inv-34: Documented failure of conservative therapy — requirement of ≥ 6 months

Covered when ALL of the following are met

Documented failure of conservative therapy: Requirement: Documented failure of ≥ six months of conventional multidisciplinary medical therapy prior to authorization for an SCS trial; specific therapies vary by indication and include examples such as physical therapy, chiropractic, prescribed home exercises, NSAIDs (unless contraindicated), activity modification, anticonvulsant or antidepressant medication, sympathetic block, physician-directed home exercises, oral medications (opioids or non-opioids), and lifestyle changes.≥ 6 months

From policy sections III.A, III.B, III.D and supporting conservative therapy requirements

Frequency Limits and Trial Requirements

SCS trial/implant (inv-36)

Trial before permanent placementA documented SCS trial of ≥ 3 days is required prior to permanent SCS implantation.

Frequency limitsNo additional frequency limits for SCS trial/implantation are specified in the cited excerpt.

Documentation expectationTrial duration and results must be documented and submitted with prior authorization and for permanent placement decisions.

Implantation, revision, and programming procedures (inv-37)

Procedures covered by listed codesCodes listed cover implantation, revision, removal, electronic analysis, and programming of spinal cord and peripheral neurostimulator systems.

No frequency limits in excerptThe cited code listings and descriptions do not specify procedural frequency limits in the provided chunks.

Imaging and Pre-implant Evaluation

Documentation Required

Obtain myelography or MRI when arachnoiditis is suspected for SCS candidacy

When arachnoiditis is a consideration for SCS candidacy (lumbosacral adhesive arachnoiditis), document imaging evidence such as myelography or magnetic resonance imaging to support the diagnosis.

Presence of arachnoiditis is usually documented by high CSF protein and/or by myelography or MRI.
Include imaging reports in the prior authorization package when arachnoiditis is suspected.

Billing Rule

Include imaging guidance documentation with codes 64596 and 64597 when performed

When submitting claims for procedures using CPT codes 64596 or 64597, include imaging guidance documentation if imaging was performed, since their descriptions state 'including imaging guidance, when performed.'

Not Covered / Exclusions

The following therapies are listed as not covered or lacking sufficient evidence under this policy: peripheral nerve stimulation (PNS), peripheral nerve field stimulation (PNFS), percutaneous electrical nerve stimulation (PENS), percutaneous electrical nerve field stimulation (PENFS), and dorsal root ganglion (DRG) stimulation. Providers should expect requests for these procedures to be reviewed with denial risk when submitted, and CPT code 0720T (PENFS, cranial nerves, without implantation) is specifically listed among codes that do not support coverage.

Policy Summary

PayerCentene

PolicySpinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation

Policy CodePolicy CP.MP.117

Change TypeMaterial updates: PENFS/PENS deemed insufficient evidencePENS criteria removedcoding updates

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with documentation showing ≥6 months of failed conservative therapy and a documented SCS trial (≥3 days) with >50% pain reduction and functional improvement.

SourceLink

On This Page

Conservative therapy duration (inv-19)

Conservative therapy durationFailure of ≥ 6 months of conventional multidisciplinary medical therapy is required prior to authorization of an SCS trial.

Therapies includedMay include physical therapy, chiropractic or prescribed home exercise program, NSAIDs (unless contraindicated), activity modification; anticonvulsant or antidepressant medications and sympathetic block for certain indications.

ApplicabilityThe ≥ 6 months requirement applies across multiple SCS indications (e.g., failed back surgery syndrome, CRPS, ischemic leg pain, other intractable pain).

Psychological evaluation / drug abuse screening (inv-20)

Psychological evaluation requirementPsychological evaluation and clearance by a qualified mental health professional revealing no inadequately controlled mental health problem is required prior to SCS trial or permanent placement.

Drug/alcohol screeningNo untreated, existing drug or alcohol dependency is allowed; strengthened criteria across indications require screening and documentation.

Provider rolesEvaluation must be performed by a qualified mental health professional and documentation submitted with prior authorization requests.

Prior Authorization

SCS Trial Requirement

SCS trial prerequisites. A trial of SCS requires documented failure of ≥ six months of conventional multidisciplinary medical therapy before authorization of a trial will be considered.

Conventional multidisciplinary medical therapy must include, when applicable: chiropractic/physical therapy or prescribed home exercise program; NSAIDs unless contraindicated or not tolerated; activity modification; physician-directed home exercises; oral medications; lifestyle changes (e.g., diet, smoking cessation, exercise)

Documentation Required

Documentation — Permanent SCS Placement

Documentation for permanent SCS placement. For approval of permanent implant following a trial, include documentation that disease-specific criteria were met, a documented trial of ≥ three days occurred, pain reduction of > 50% from the trial associated with functional improvement was achieved, and the same brand and model of the generator used for the trial will be used for permanent placement.

Document trial length (≥ 3 days) and objective/subjective pain reduction (> 50%) with functional improvement
Confirm brand/model continuity between trial generator and permanent device
Include evidence that initial indication met SCS medical necessity criteria (e.g., failed back surgery syndrome, CRPS, chronic ischemic leg pain, etc.)

Documentation Required

Documentation and Coding Guidance

Documentation and coding guidance. Providers should reference up-to-date CPT and HCPCS coding resources and include supporting clinical documentation (indication, prior conservative therapy, trial details, pain scores, functional improvement, psychological clearance, substance use status) with prior authorization and claims submissions.

Include clinical notes that demonstrate failure of conservative therapy, cognitive ability to manage stimulator, psychological evaluation/clearance, and absence of untreated substance dependency
Attach trial stimulation reports, pain score comparisons, and device brand/model information
Codes listed in the policy are informational; inclusion or exclusion does not guarantee coverage

Step Therapy

PENS / PENFS Step Therapy Status

PENS/PENFS step therapy and coverage status. Percutaneous electrical nerve stimulation (PENS) and percutaneous electrical nerve field stimulation (PENFS) are categorized as having insufficient evidence to support efficacy for any indication; step therapy or prior authorization criteria for these therapies have been removed and requests may be denied.

PENS and PENFS are considered not supported by current evidence per this policy
CPT 0720T (PENFS) specifically listed as not supporting coverage

PENFS / PENS definitions (inv-32)

PENFS / PENS definitionPercutaneous electrical nerve stimulation (PENS) uses fine needles as electrodes placed at dermatomal levels; percutaneous electrical nerve field stimulation (PENFS) targets an area of pain rather than a specific nerve.

Technique notePENS bypasses local skin resistance and delivers electrical current closer to affected tissues compared with transcutaneous methods.

Policy stancePer policy, PENFS/PENS are designated as having insufficient evidence to support efficacy for any indication.

Neurostimulator implantation codes (inv-33)

CPT implantation/revision/programming codesRelevant CPT codes include 63650, 63655, 63685, 64555, 64575, 64585, 64590, 64595, 64596, 64597, 64598, 64999, 95970, 95971, 95972 for implantation, revision, removal, and electronic analysis/programming.

HCPCS supply/device codesRelevant HCPCS codes include L8678, L8679, L8680, L8681, L8682, L8683, L8685, L8686, L8687, L8688 for implantable neurostimulator devices and supplies.

Imaging guidance noteSome CPT codes (e.g., 64596, 64597) include imaging guidance in their descriptions when performed.