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    v1.0.30
    OpenPayerPolicy UpdatesPain ManagementPremera PNS Policy Coverage Update | OpenPayer
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    ModifiedPremera Blue Cross of WashingtonPolicy N/A

    Implantable Peripheral Nerve Stimulation for Chronic Pain and Other Conditions

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    Coverage of implantable peripheral nerve stimulation for chronic pain and implantable tibial nerve stimulation for urinary dysfunction; these services are investigational for all described indications.

    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyImplantable Peripheral Nerve Stimulation for Chronic Pain and Other Conditions
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateNov 1, 2026
    Last ReviewNov 1, 2026
    Next Review DateN/A
    Key ActionTreat implantable peripheral nerve stimulation and implantable tibial nerve stimulation as investigational for all indications.
    SourceLink

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    POLICY UPDATE CHANGES

    The policy was restructured from a single blanket indication into five indication-specific conditions: peripheral neuropathic pain, post-amputation or phantom-limb pain, persistent post-surgical pain, axial or low back pain including persistent spinal pain syndrome, and craniofacial pain.

    Peripheral nerve stimulator systems are addressed separately and remain investigational for all indications.

    CPT code 64598 was added in the November 2026 coding update.

    HCPCS code C1607 was removed from this policy and moved to policy 10.01.533, Non-covered Experimental/Investigational Services.

    InvestigationalPeripheral nerve stimulation coverage
    5Indication-specific conditions
    30 daysTrial stimulation period
    50% reductionTypical PNS response threshold
    2 RCTsPeripheral neuropathic pain RCTs

    Coverage Criteria

    Implantable Peripheral Nerve Stimulation for Chronic Pain

    Investigational for all indications.

    Investigational chronic pain use: A trial or permanent placement of an implantable peripheral nerve stimulator for management of chronic pain is investigational for all indications, including peripheral neuropathic extremity pain, post-amputation or phantom-limb pain, post-surgical pain, axial or low-back pain including persistent spinal pain syndrome, and craniofacial pain.

    Implantable Tibial Nerve Stimulation

    Investigational for all indications.

    Investigational implantable tibial nerve stimulation: Implantable tibial nerve stimulation delivered by an implantable peripheral neurostimulator system, including eCoin, Altaviva, and Revi System devices, is investigational for all indications, including non-neurogenic urinary dysfunction such as overactive bladder.

    Peripheral Nerve Stimulator Systems

    Peripheral nerve stimulator systems remain investigational for all indications.

    Investigational status: Peripheral nerve stimulator systems remain investigational for all indications.

    No covered indication criteria are provided in this policy.

    Implantable peripheral nerve stimulation for chronic pain is investigational for all indications, including peripheral neuropathic extremity pain, post-amputation or phantom-limb pain, post-surgical pain, axial or low-back pain, persistent spinal pain syndrome, and craniofacial pain. This applies to both trial and permanent placement of an implantable peripheral nerve stimulator.

    Implantable tibial nerve stimulation delivered by an implantable peripheral neurostimulator system is investigational for all indications. This includes systems such as eCoin, Altaviva, and Revi System, and use for non-neurogenic urinary dysfunction, including overactive bladder.

    The listed SPRINT, Nalu, StimRouter, Moventis PNS, and related systems are not intended to treat pain in the craniofacial region.

    Coding and Operational Thresholds

    CPTCPTExperimental
    0816TOpen insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (e.g., array or leadless), and pulse generator or receiver, including analysis, programming, and imaging guidance, when performed, posterior tibial nerve; subcutaneous.
    0817TOpen insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (e.g., array or leadless), and pulse generator or receiver, including analysis, programming, and imaging guidance, when performed, posterior tibial nerve; subfascial.
    0818TRevision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subcutaneous.
    0819TRevision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subfascial.
    64575Open implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve).
    64585Revision or removal of peripheral neurostimulator electrode array.
    64590Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling.
    64595Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver.
    64596Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; initial electrode array.
    64597Insertion 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).
    1–10 of 12
    1/2
    HCPCSHCPCSExperimental
    A4438Adhesive clip applied to the skin to secure external electrical nerve stimulator controller, each.
    C1767Generator, neurostimulator (implantable), nonrechargeable.
    C1778Lead, neurostimulator (implantable).
    C1787Patient programmer, neurostimulator.
    C1816Receiver and/or transmitter, neurostimulator (implantable).
    C1883Adapter/extension, pacing lead or neurostimulator lead (implantable).
    C1897Lead, neurostimulator test kit (implantable).
    C9807Nerve stimulator, percutaneous, peripheral (e.g., SPRINT peripheral nerve stimulation system), including electrode and all disposable system components, non-opioid medical device.
    L8679Implantable neurostimulator, pulse generator, any type.
    L8680Implantable neurostimulator electrode, each.
    1–10 of 18
    1/2
    FDA Product CodesFDA
    GZFFDA product code for peripheral nerve stimulation devices
    NHIFDA product code for peripheral nerve stimulation devices
    FDA 510(k) ClearancesFDA 510(k)
    K181422510(k) clearance for SPRINT Peripheral Nerve Stimulation System
    K183579510(k) clearance for Nalu Neurostimulation Kit and related configurations
    FDA 510(k) ClearancesFDA 510(k)
    K191435510(k) clearance for Nalu Neurostimulation System components
    K190047510(k) clearance for StimRouter Neuromodulation System
    K200482510(k) clearance for StimRouter Neuromodulation System
    K211965510(k) clearance for StimRouter Neuromodulation System
    K200848510(k) clearance for Moventis PNS
    K202781510(k) clearance for Neuspera Neurostimulation System
    FDA Product Codes for Peripheral Nerve Stimulation Devicesmixed
    GZF
    NHI
    FDA Product Codes for Tibial Nerve Stimulation Devicesmixed
    QLK
    QPT
    FDA Product Codemixed
    QXM
    CPT Codes Referenced in Policy HistoryCPT
    64575
    64596
    64597
    64598
    64999
    0816T
    0817T
    0818T
    0819T
    0988T
    1–10 of 11
    1/2
    HCPCS Codes Referenced in Policy HistoryHCPCS
    C1767
    C1778
    C1787
    A4438
    C1816
    C1883
    C1897
    C1607
    C9807
    PNS trial response
    ThresholdAt least 50% pain reduction
    UseEvaluated during the temporary PNS trial
    Next stepSupports consideration of permanent implantation or continued external stimulation
    Trial device duration
    Maximum durationNo longer than 30 days

    Provider Actions and Coverage Status

    Denial Risk

    Chronic pain implantable PNS is investigational

    A trial or permanent placement of an implantable peripheral nerve stimulator for management of chronic pain is investigational for all indications, including peripheral neuropathic extremity pain, post-amputation or phantom-limb pain, post-surgical pain, axial or low-back pain including persistent spinal pain syndrome, and craniofacial pain.

    Denial Risk

    Implantable tibial stimulation is investigational

    Implantable tibial nerve stimulation delivered by an implantable peripheral neurostimulator system—including eCoin, Altaviva, and Revi System devices—is investigational for all indications, including non-neurogenic urinary dysfunction such as overactive bladder.

    Denial Risk

    Peripheral nerve stimulator systems remain investigational

    Background

    Peripheral nerve stimulation delivers electrical impulses directly to a peripheral nerve through implanted or percutaneous leads and electrodes connected to a pulse transmitter. The technique has been studied for several chronic pain conditions, including peripheral neuropathic, post-amputation, post-surgical, axial or low-back, and craniofacial pain, as well as implantable tibial stimulation for urinary dysfunction.

    Definitions

    Peripheral nerve stimulation
    TechniqueImplantation of a small device that sends low levels of electricity to part of a peripheral nerve
    MechanismThe electrical current is thought to interfere with nerve-signal transmission
    Intended effectsReduce pain or improve muscle movement
    Chronic noncancer pain
    DefinitionPersistent noncancer pain lasting more than 3 months
    Pain typeNoncancer pain
    DurationMore than 3 months

    Conservative Treatment Requirements

    Failure of Conservative Treatment Options for Lower-Extremity Neuropathic Pain

    PNS may be considered when conservative treatment options have failed.

    Conservative treatment failure: For lower-extremity neuropathic pain, PNS may be considered following failure of conservative treatment options.

    Failure of Conservative Treatment Options for Lower-Extremity Post-Amputation Pain

    PNS may be considered when conservative treatment options have failed.

    Conservative treatment failure: For lower-extremity post-amputation pain, PNS may be considered following failure of conservative treatment options.

    Imaging and Guidance Requirements

    Note

    Use imaging guidance for PNS placement as appropriate

    For peripheral nerve stimulation, leads may be placed using ultrasound guidance and/or fluoroscopic guidance. Guidance may be used for temporary or permanent placement.

    Documentation Required

    Obtain a diagnostic ultrasound-guided nerve block

    For upper-extremity mononeuropathy PNS, proceed following a positive diagnostic ultrasound-guided nerve block of the targeted nerve.

    Not Covered Services and Systems

    Not covered: Implantable peripheral nerve stimulation for chronic pain is investigational for all indications, including peripheral neuropathic extremity pain, post-amputation or phantom-limb pain, post-surgical pain, axial or low-back pain, persistent spinal pain syndrome, and craniofacial pain.

    Not covered: Implantable tibial nerve stimulation delivered by an implantable peripheral neurostimulator system is investigational for all indications, including non-neurogenic urinary dysfunction such as overactive bladder.

    The listed SPRINT, Nalu, StimRouter, Moventis PNS, and Neuspera systems are not intended to treat pain in the craniofacial region.

    Not covered: Trial or permanent placement of an implantable peripheral nerve stimulator for chronic pain, and implantable tibial nerve stimulation delivered by an implantable peripheral neurostimulator system, are investigational for all indications.

    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyImplantable Peripheral Nerve Stimulation for Chronic Pain and Other Conditions
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateNov 1, 2026
    Last ReviewNov 1, 2026
    Next Review DateN/A
    Key ActionTreat implantable peripheral nerve stimulation and implantable tibial nerve stimulation as investigational for all indications.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Operational ThresholdsProvider Actions and Coverage StatusBackgroundDefinitionsConservative Treatment RequirementsImaging and Guidance RequirementsNot Covered Services and Systems
    PurposeTrial stimulation to determine efficacy
    Device statusTrial devices are used before recommendation for a permanent, long-term device
    Post-amputation pain response
    Responder thresholdAt least 50% pain reduction
    ConditionChronic post-amputation pain, including residual-limb and phantom-limb pain
    Treatment evaluatedTemporary 60-day peripheral nerve stimulation
    Craniofacial pain response
    Responder thresholdAt least 50% pain relief
    ConditionRefractory chronic craniofacial neuropathic pain
    Treatment evaluatedPermanent peripheral nerve stimulation
    Implantable tibial stimulation response
    Response thresholdAt least 50% reduction in urgency urinary incontinence episodes
    ConditionNon-neurogenic urinary dysfunction, including overactive bladder
    Treatment evaluatedImplantable tibial nerve stimulation
    ReActiv8 treatment response
    Pain thresholdAt least 30% reduction in visual analog scale
    Medication requirementNo increase in pain medications
    Primary endpointComposite treatment response at 120 days

    Peripheral nerve stimulator systems remain investigational for all indications. Do not assume that FDA clearance or a listed system creates a covered indication under this policy.

    Percutaneous electrical nerve stimulation
    Delivery methodElectrical stimulation delivered through needle electrodes inserted into the skin
    Electrode locationAround or immediately adjacent to the nerves serving the painful area
    Implantation statusThe stimulation devices are not implanted
    Percutaneous neuromodulation therapy
    Delivery methodElectrical stimulation delivered through very thin filament electrode arrays
    Electrode locationInserted directly into deep tissues near the area causing pain
    Implantation statusThe stimulation devices are not implanted
    PNS for chronic pain
    AbbreviationPNS
    MeaningPeripheral nerve stimulation
    UseTreatment of peripheral, neuropathic, chronic pain
    Temporary PNS
    TreatmentPeripheral nerve stimulation
    Duration60 days
    IndicationChronic post-amputation pain
    iTNS
    AbbreviationiTNS
    MeaningImplantable tibial nerve stimulation
    UseNon-neurogenic urinary dysfunction, including overactive bladder and urgency urinary incontinence
    Revi System
    Device typeImplanted tibial electrical urinary continence device
    Stimulation siteTibial nerve near the ankle
    Intended useTreat urgency urinary incontinence
    PNS abbreviation
    AbbreviationPNS
    Full termPeripheral nerve stimulation
    MeaningPNS is the abbreviation for peripheral nerve stimulation