Currentpartners_health_managementPolicy NC.CP.MP.117

Clinical Policy: Spinal Cord Stimulation, Peripheral Nerve and Percutaneous Electrical Nerve Stimulation

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Defines medical necessity and coverage criteria for spinal cord stimulation (SCS) and states coverage stance for peripheral nerve stimulation (PNS), peripheral nerve field stimulation (PNFS), percutaneous electrical nerve stimulation (PENS), and percutaneous electrical nerve field stimulation (PENFS) for members of health plans affiliated with Partners Health Management/Carolina Complete Health.

Policy Summary

Payerpartners_health_management

PolicySpinal Cord Stimulation, Peripheral Nerve and Percutaneous Electrical Nerve Stimulation

Policy CodePolicy NC.CP.MP.117

Change TypeNo material changes

Effective Date

Last ReviewJan 1, 2026

Next Review DateJan 1, 2026

Key ActionObtain prior authorization demonstrating a ≥48-hour SCS trial with >50% pain reduction and documentation of ≥6 months of prior conservative therapy before permanent implantation.

SourceLink

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Currentpartners_health_managementPolicy NC.CP.MP.117

Clinical Policy: Spinal Cord Stimulation, Peripheral Nerve and Percutaneous Electrical Nerve Stimulation

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Policy Summary

Payerpartners_health_management

PolicySpinal Cord Stimulation, Peripheral Nerve and Percutaneous Electrical Nerve Stimulation

Policy CodePolicy NC.CP.MP.117

Change TypeNo material changes

Effective Date

Last ReviewJan 1, 2026

Next Review DateJan 1, 2026

Key ActionObtain prior authorization demonstrating a ≥48-hour SCS trial with >50% pain reduction and documentation of ≥6 months of prior conservative therapy before permanent implantation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥6 moConservative therapy duration (many indications)

48 hRequired trial duration

>50%Required trial pain reduction

InsufficientPENS/PNS/PNFS/PENFS stance

InsufficientDRG stimulation evidence

~20Supporting CPT/HCPCS codes

Coverage Criteria — Neuromodulation Therapies

inv-01: SCS Indications and Requirements

Spinal cord stimulation (SCS) is medically necessary when ALL of the following criteria for the specific indication are met:

Refractory chronic stable angina (case-by-case): A trial of SCS for refractory chronic stable angina pectoris may be considered on a case-by-case basis when ALL criteria are met: (1) continued angina after PCI or CABG; (2) not a candidate for further revascularization; (3) angina NYHA class III or IV; (4) reversible ischemia documented by a symptom-limited treadmill exercise test; (5) optimal pharmacotherapy for at least one month including maximal tolerated dose of at least two drug classes (long-acting nitrates, beta-blockers, or calcium channel antagonists); (6) pain is chronic, refractory, and interferes with ADLs; (7) demonstrated cognitive ability to manage stimulator; (8) no inadequately treated major psychiatric disorders; (9) willingness to cease any inappropriate drug use prior to implantation.

See chunk 8

inv-02: Insufficient Evidence / Not Supported

The following neuromodulation therapies are considered to have insufficient evidence and not supported:

PENS/PNS/PNFS/PENFS: Percutaneous electrical nerve stimulation (PENS), peripheral nerve stimulation (PNS), peripheral nerve field stimulation (PNFS), and percutaneous electrical nerve field stimulation (PENFS) are considered to have insufficient evidence to support efficacy for any indication.

See chunks 3-4

inv-03: Insufficient evidence — DRG stimulation

Policy contains sections with varying stances by modality and indication; where evidence is insufficient the policy states that explicitly.

DRG Stimulation for CRPS: Hayes assessment concluded there is insufficient evidence to determine effectiveness and safety of dorsal root ganglion (DRG) stimulation for adults with complex regional pain syndrome (CRPS). Limited small studies exist but are insufficient for definitive conclusions; additional high-quality comparative studies are recommended.

See chunk 18 and policy revision notes in chunks 28-29

inv-04: Insufficient evidence — PENS/PENFS

Policy revision history documents additions and changes to indications, trial requirements, and statements of insufficient evidence for certain modalities (e.g., PENS/PENFS).

PENS/PENFS: Revision history indicates percutaneous electrical nerve stimulation (PENS) and percutaneous electrical nerve field stimulation (PENFS) were added to the Insufficient Evidence category in recent updates; PENFS was specifically cited as lacking evidence for any indication, including IBS.

See revision entries in chunks 25, 27, and 29

The policy states that PENS (percutaneous electrical nerve stimulation), PNS (peripheral nerve stimulation), PNFS (peripheral nerve field stimulation), and PENFS (percutaneous electrical nerve field stimulation) are not supported due to insufficient evidence to demonstrate efficacy for any indication.

The policy was revised to add a specific statement (Section IV) that there is insufficient evidence to support dorsal root ganglion (DRG) stimulation; background material was updated to reflect the limited and inconclusive evidence for DRG stimulation, particularly in complex regional pain syndrome (CRPS). The revision history also documents updates clarifying insufficient-evidence designations for other percutaneous therapies.

For Medicaid members, the policy notes that state Medicaid coverage provisions take precedence when they conflict with this clinical policy; providers should consult the applicable state Medicaid manual for any differing coverage rules.

Use of PENS, PNS, PNFS, and PENFS for any indication is considered unsupported by the available evidence and is therefore treated as not supported by this policy; requests for these therapies may be denied on efficacy grounds.

The policy explicitly states that percutaneous electrical nerve field stimulation (PENFS) has insufficient evidence to support efficacy for any indication (including irritable bowel syndrome) and has been placed in the insufficient-evidence category in recent revisions.

Coding and Reimbursement

Coding Implicationsmixed

No codes listed

CPT Codes That Do Not Support Coverage CriteriaCPTNot 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

1–10 of 15

1/2

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 neurostimimulator 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, nonchargeable, includes extension
L8687	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
L8688	Implantable neurostimulator pulse generator, dual array, nonchargeable, includes extension

Codes referenced genericallymixed

No codes listed

SCS trial pain reduction threshold

SCS trial pain reduction threshold> 50% pain reduction from the trial associated with functional improvement

Associated requirementFunctional improvement must accompany the >50% pain reduction

Documentation requiredDocumented pain reduction of >50% from the trial prior to permanent placement

SCS trial duration

Minimum SCS trial duration≥ 48 hours (documented trial of at least 48 hours)

Historical change

Provider Actions and Prior Authorization

Prior Authorization

Obtain prior authorization and document trial success for SCS

Prior authorization is required for spinal cord stimulation (SCS) and must demonstrate that disease-specific SCS criteria and prior conservative therapy requirements have been met, and must document an SCS trial of at least 48 hours with >50% pain reduction and associated functional improvement prior to permanent implantation.

Demonstrate failure of ≥ 6 months of conventional multidisciplinary medical therapy when required by indication.
Document trial duration (≥ 48 hours) and documented pain reduction of > 50% with functional improvement.
Permanent generator must be same brand and model used during trial.

Billing Rule

Use the policy-listed CPT/HCPCS codes when requesting authorization

Conservative Treatment and Trial Requirements

inv-42: Conservative therapies and a trial of stimulation are implied requirements in the policy criteria (exact durations and interventions not present in this excerpt).

Conservative therapies and a trial of stimulation are implied requirements in the policy criteria (exact durations and interventions not present in this excerpt).

Conservative therapies and trial stimulation (policy implication): Policy history and criteria updates imply that conservative therapies and a documented trial of stimulation are required components of SCS candidacy; details on specific interventions and durations are referenced elsewhere in the policy and revision log.

See revision history in chunks 25 and 27 for context

Frequency and Trial Limits

SCS trial — documentation requirement

SCS trial prior to permanent implantDocumented trial of at least 48 hours is required prior to permanent SCS implantation

Pain reduction requirementTrial must demonstrate >50% pain reduction associated with functional improvement

Device consistencyThe same brand and model of generator used for the trial should be used for permanent placement

Frequency limits — coding updates (not specified)

Frequency limits specifiedNot specified in this excerpt; coding updates and additions were noted but no frequency caps provided

Coding updates notedAnnual reviews updated codes and added codes supporting coverage criteria (see coding sections)

Imaging and Diagnostic Requirements

Documentation Required

Document myelography or MRI findings for arachnoiditis evaluation

For arachnoiditis indications, document evaluation findings such as high CSF protein and/or myelography or MRI results when applicable.

Billing Rule

Include imaging guidance documentation for peripheral percutaneous electrode procedures when performed

When billing for insertion or replacement of percutaneous electrode arrays for peripheral nerve procedures, account for imaging guidance when performed—some listed CPT codes (e.g., 64596, 64597) include imaging guidance.

Include imaging guidance documentation if performed to match code descriptors.

Note

Definitions — Neuromodulation Terms

Peripheral Nerve Stimulation (PNS)

DefinitionPeripheral nerve stimulation (PNS): stimulation of peripheral nerves with leads placed adjacent or parallel to the affected nerve; may be used in a trial or for permanent placement.

Intended useIntended to decrease chronic and acute pain by stimulating peripheral nerves

Trial capabilityPNS can be used in a trial of pain relief effectiveness prior to permanent implantation

Peripheral Nerve Field Stimulation (PNFS)

DefinitionPeripheral nerve field stimulation (PNFS): leads are placed in the region where the pain is felt to stimulate smaller peripheral nerves and nerve endings.

Use caseUseful when a single nerve does not clearly service the painful area

Background and Scope

Background: PNS, PNFS, PENS, PENFS, and SCS are neuromodulation techniques that deliver electrical stimulation to peripheral nerves, nerve fields, or the dorsal columns to reduce chronic or acute pain. Evidence quality varies across modalities: SCS has supportive data for multiple neuropathic and ischemic pain syndromes, while the evidence for PNS/PNFS/PENS/PENFS is limited or insufficient; DRG stimulation evidence is currently insufficient for firm conclusions.

Not Covered / Exclusions

Not covered: PENS, PNS, and PNFS are listed as therapies the policy does not support due to insufficient evidence. The policy and its revision history also identify PENFS and certain CPT-coded percutaneous electrical nerve field stimulation services as unsupported; providers should expect these services to be treated as not covered under this policy absent compelling new evidence or state-specific coverage rules.

Policy Summary

Payerpartners_health_management

PolicySpinal Cord Stimulation, Peripheral Nerve and Percutaneous Electrical Nerve Stimulation

Policy CodePolicy NC.CP.MP.117

Change TypeNo material changes

Effective Date

Last ReviewJan 1, 2026

Next Review DateJan 1, 2026

Key ActionObtain prior authorization demonstrating a ≥48-hour SCS trial with >50% pain reduction and documentation of ≥6 months of prior conservative therapy before permanent implantation.

SourceLink

On This Page

Policy criterion revised from >3 days to at least 48 hours (see revision history)

Prior authorization implicationPrior authorization must demonstrate trial duration ≥48 hours

Conservative therapy duration

Conservative therapy duration before SCS trial≥ 6 months of conventional multidisciplinary medical therapy

Examples of conservative therapiesPhysical therapy/chiropractic or prescribed home exercise, NSAIDs unless contraindicated, activity modification

Documentation requirementProviders must document failure of ≥6 months of conservative therapy prior to trial

Trial stimulation duration

Trial stimulation duration (current)At least 48 hours for an adequate trial of stimulation

Historical revisionLength of an adequate trial of stimulation was changed from >3 days to at least 48 hours in a policy revision

DocumentationRevision history notes the criteria change; ensure records reflect trial length per current policy

When requesting authorization or submitting claims for implantation, revision, removal, or programming of neurostimulator systems, include the policy-listed CPT and HCPCS codes that support coverage criteria.

Include CPT codes such as 63650, 63655, 63685, 64555, 64575, 64596–64598, 95970–95972, and others listed in the policy.
Include HCPCS codes such as L8678, L8679, L8680, L8681, L8682, L8683, L8685–L8688 as applicable.

Note

Adhere to Health Plan administrative and benefit document rules

Follow the Health Plan's administrative policies and the member's benefit documents for prior authorization and coverage determinations; obtain any required authorizations per those rules.

Coverage decisions are subject to terms, conditions, exclusions and limitations of the coverage documents and applicable Health Plan-level administrative policies.
This policy does not guarantee payment; check plan-specific effective dates and requirements.

Step Therapy

Document ≥6 months of conservative multidisciplinary therapy before SCS trial

Document failure of at least 6 months of conventional multidisciplinary medical therapy prior to an SCS trial for most indications; list of therapies includes physical therapy/chiropractic, prescribed home exercise, NSAIDs unless contraindicated, activity modification, and other modality-specific examples.

Record duration and specific therapies tried (e.g., physical therapy, chiropractic care, prescribed home exercise programs).
Note use or intolerance of NSAIDs and activity modification efforts.

Documentation Required

Include historical conservative care and trial stimulation details with requests

Policy history documents that conservative therapies and trial stimulation requirements have been part of prior criteria updates, reinforcing the need to record prior conservative care and trial details in authorization requests.

Include prior revision notes or documentation of previously attempted conservative measures if available.
Ensure trial stimulation length and procedures are described, since trial requirements have changed historically.

Documentation Required

Document trial duration, pain reduction, functional improvement, and device used

Document the SCS trial (at least 48 hours) and show >50% pain reduction from the trial with associated functional improvement prior to permanent SCS implantation; specify that the permanent device is the same brand/model used during the trial.

Record trial start and end times to confirm ≥48-hour duration.
Provide objective and subjective measures demonstrating >50% pain reduction and functional gains.
Document device brand and model used during trial and planned permanent implant.

Documentation Required

Provide comprehensive pre-implant documentation including cognitive and psychiatric assessment

Before implantation, document prior therapies (≥6 months), the patient's cognitive ability to manage a stimulator, absence of inadequately treated major psychiatric disorders, and willingness to cease inappropriate drug use.

Include cognitive assessment results and psychiatric history addressing untreated major disorders.
Document patient agreement to cease inappropriate drug use prior to implantation.

Billing Rule

Use up-to-date professional coding guidance when billing

Reference current professional coding guidance and include the appropriate CPT/HCPCS codes when submitting claims; policy code lists are informational and inclusion/exclusion of codes does not guarantee coverage.

Verify codes against the latest CPT/HCPCS manuals before claim submission.
Do not rely solely on the policy's code list to determine coverage—confirm with the Health Plan.

Documentation Required

Ensure documentation and administrative compliance with the member's coverage documents

Follow Health Plan-level administrative policies and the member's coverage documents when submitting claims or requesting coverage; this policy guides medical necessity but is not a guarantee of payment.

Ensure prior authorization workflows and submission requirements conform to plan rules.
Confirm effective dates and any state- or plan-specific modifications.

Denial Risk

Risk of denial for PENS/PNS/PNFS/PENFS due to insufficient evidence

Requests for PENS, PNS, PNFS, or PENFS may be denied because the policy states there is insufficient evidence to support these therapies for any indication.

Avoid requesting authorization for these modalities for indications the policy labels as unsupported unless submitting compelling new evidence.
Expect denials on efficacy grounds for PENS, PNS, PNFS, and PENFS per policy statements.

Denial Risk

Unsupported CPT code 0720T may trigger denial

Do not use CPT 0720T (percutaneous electrical nerve field stimulation, cranial nerves, without implantation) as a supporting code for covered indications; billing this code may trigger denial because it does not support coverage criteria.

If considering PENFS-related services, note CPT 0720T is listed as not supporting coverage criteria.
Use appropriate covered CPT/HCPCS codes from the policy when billing for implantable neuromodulation services.

Note

Confirm coverage document compliance before submission

Coverage decisions are subject to the terms, conditions, exclusions, and limitations of the member's coverage documents; inconsistencies between this clinical policy and coverage documents may affect payment.

Verify member-specific benefits and exclusions before proceeding with authorization or implantation.
State Medicaid provisions may take precedence where applicable.

Action for providersFollow Health Plan administrative policies and prior authorization guidance for any frequency-related determinations

Frequency limits — placeholder

Frequency limits placeholderNo frequency limits provided in the available excerpt

Administrative noteCoverage determinations subject to Health Plan terms, conditions, exclusions and administrative policies

RecommendationRefer to member benefit documents or contact Health Plan for any frequency-specific rules

Relation to PNSPNFS targets nerve fields rather than a specific named peripheral nerve

Percutaneous Electrical Nerve Stimulation (PENS)

DefinitionPercutaneous electrical nerve stimulation (PENS): fine needles used as electrodes placed in soft tissues or muscles at dermatomal levels to deliver electrical current closer to affected tissues.

MechanismBypasses local skin resistance compared to transcutaneous stimulation to deliver current closer to target tissues

Clinical statusPENS was added to the policy's insufficient evidence category in recent revisions (see revision history)

Percutaneous Electrical Nerve Field Stimulation (PENFS)

DefinitionPercutaneous electrical nerve field stimulation (PENFS): variation of PENS that targets an area of pain rather than a specific nerve; includes devices such as IB-Stim cleared by FDA for adolescent IBS

Evidence statementPolicy states there is insufficient evidence to support the efficacy of PENFS for any indication, including IBS

Research noteStudies are limited and additional research is needed before routine recommendation

Spinal Cord Stimulation (SCS / DCS)

DefinitionSpinal cord stimulation (SCS/DCS): device-based electrical stimulation of the dorsal aspect of the spinal cord to relieve chronic neuropathic pain syndromes

IndicationsUsed for conditions such as failed back surgery syndrome and CRPS when conservative therapies have failed

Expected benefitApproximately 50% of selected patients may achieve pain relief, reducing need for analgesics and further surgery

Dorsal Root Ganglion (DRG) stimulation — evidence

DefinitionDorsal root ganglion (DRG) stimulation: targeted stimulation of the dorsal root ganglion for pain control

Evidence statusHayes review concludes there is insufficient evidence to determine effectiveness and safety of DRG stimulation for adults with CRPS

Research needLimited small studies exist but are inadequate; additional high-quality comparative studies recommended

Dorsal Root Ganglion (DRG) stimulation — clinical note

Technique descriptionDRG stimulation is a neuromodulation approach targeting the dorsal root ganglion

CRPS conclusionCurrent evidence for effectiveness and safety in adults with CRPS is insufficient per Hayes assessment

Clinical implicationDRG stimulation is listed in the policy as having insufficient evidence and not supported for CRPS

Health Plan — definition and administrative context

DefinitionHealth Plan: a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or its affiliates.

Policy useThis clinical policy is a guide to medical necessity and does not guarantee payment

Administrative noteCoverage decisions are subject to the Health Plan's terms, conditions, exclusions, limitations, and applicable laws/regulations