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Modifiedpriority healthPolicy 91634

Peripheral Nerve Stimulation

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This policy governs coverage and medical necessity criteria for transcutaneous, percutaneous, auricular, and implanted peripheral nerve stimulation devices and related electrical stimulation therapies for pain and select other indications (e.g., hyperemesis gravidarum), affecting Priority Health commercial and Medicaid members.

Policy Summary

Payerpriority health

PolicyPeripheral Nerve Stimulation

Policy CodePolicy 91634

Change TypeClarification & reference update

Effective DateJun 1, 2026

Last ReviewMay 1, 2026

Next Review Date

Key ActionObtain prior authorization for permanently implanted peripheral nerve stimulators and submit documentation demonstrating medical necessity.

SourceLink

POLICY UPDATE CHANGES

SPRINT PNS is a unique device in that it's intended for temporary (60-day) implantation to provide durable symptom relief and it is considered not medically necessary.

Updated background and references

multiplestimulator types addressed

2-monthTENS initial trial

60 daysSPRINT PNS duration

NMNSPRINT PNS stance

>=50%Therapeutic trial threshold

Coverage and Medical Necessity Criteria

inv-01: Transcutaneous electrical nerve stimulators (TENS) — continuation criteria and trial requirements

Authorization beyond the initial two-month trial is covered when ALL of the following are documented:

TENS continuation criteria: Authorization beyond the initial two-month trial requires documentation of at least two of the following: increased physical activity; decreased pain; decreased use of analgesics.at least 2 of 3

Initial two-month trial does not require prior authorization (first 2-months covered for commercial and Medicaid).

inv-02: Percutaneous Electrical Nerve Field Stimulation (IB-Stim) — pediatric functional abdominal pain criteria (ALL required)

IB-Stim may be considered medically necessary when ALL of the following are met:

IB-Stim criteria: Member age 8-21; chronic abdominal pain meeting Rome IV criteria for abdominal pain–related functional gastrointestinal disorders; organic causes of abdominal pain have been ruled out; failure of at least one form of conservative management (e.g., hypnotherapy, cognitive behavioral therapy, soluble dietary fiber supplement, lactobacillus rhamnosus probiotic); failure of at least two medications used to treat abdominal pain with at least one being hyoscyamine or dicyclomine unless contraindicated; only one course of auricular neurostimulation will be considered medically necessary.

Policy Summary

Payerpriority health

PolicyPeripheral Nerve Stimulation

Policy CodePolicy 91634

Change TypeClarification & reference update

Effective DateJun 1, 2026

Last ReviewMay 1, 2026

Next Review Date

Key ActionObtain prior authorization for permanently implanted peripheral nerve stimulators and submit documentation demonstrating medical necessity.

SourceLink

On This Page

IB-Stim is the only auricular neurostimulation device that will be considered medically necessary; repeat treatments are not supported.

inv-03: Percutaneous electrical nerve stimulation (PENS) and percutaneous neuromodulation therapy (PNT) — top-level node

PENS/PNT stance: Priority Health considers PENS and PNT NOT medically necessary for ANY indication due to insufficient evidence in the published peer-reviewed literature.NA

Includes devices classified under FDA product code NHI (examples listed: SPRINT PNS, Smartpatch PNS, Primary Relief, Deepwave, Vertis PNT).

inv-04: Permanently implanted peripheral nerve stimulators — criteria for medical necessity (ALL required)

Permanently implanted peripheral nerve stimulators may be considered medically necessary only when ALL of the following are met:

Implanted PNS criteria: Member has a diagnosis of one or more specified conditions (e.g., reflex sympathetic dystrophy, causalgia, plexus avulsion, operative trauma, entrapment neuropathies, injection injuries); objective evidence of pathology (e.g., electromyography); member is refractory to one or more conservative therapies (analgesics, physical therapy, local injection); member exhibits no psychological contraindications; member is not addicted to any drug; member has completed a successful two-week trial of transcutaneous stimulation resulting in at least a 50% reduction in pain.all

Prior authorization is required for permanently implanted peripheral nerve stimulators.

inv-05: TOMAC peroneal nerve stimulation for RLS (Commercial, Medicaid) — top-level node

TOMAC stance: Priority Health considers TOMAC peroneal nerve stimulation therapy NOT medically necessary for restless legs syndrome (RLS) due to insufficient evidence of safety and effectiveness.NA

Medicare Advantage addressed in separate policy No. 91648.

inv-06: Restorative neurostimulation (ReActiv8) — top-level node

ReActiv8 stance: Although FDA Premarket Approval (PMA) was granted for ReActiv8®, Priority Health considers restorative neurostimulation (ReActiv8) unproven and NOT medically necessary due to insufficient evidence of efficacy.NA

Device indication and FDA classification noted; larger comparative studies are needed to demonstrate efficacy.

inv-07: Baseline coverage conditions — Covered when ALL of the following are met

Covered when ALL of the following are met:

Therapeutic trial before permanent PNS: A therapeutic trial with a temporary electrode demonstrating at least 50% analgesia is required prior to eligibility for permanent peripheral nerve stimulation implantation.>=50%

Document trial method and objective pain reduction.

TENS initial trial coverage: No prior authorization is required for the initial two-month trial of transcutaneous electrical nerve stimulation (TENS) for commercial and Medicaid; Medicare requires prior authorization for rentals from month one.2 months

See applicable ICD-10 codes and CPT/HCPCS codes for billing and coverage specifics.

inv-08: Medical Necessity Review — Coverage and medical necessity determinations

Coverage and medical necessity determinations:

Medical Necessity Review: When prior authorization is required, providers must submit documentation demonstrating medical necessity. Individual case review may allow coverage for investigational yet promising treatments with prior plan approval; determinations for experimental/investigational care will be made by a Priority Health medical director or clinical pharmacist.

Access to external guideline tools (Evicore, InterQual, TurningPoint) is available via Priority Health Prism Authorization Criteria Lookup.

inv-09: Not Medically Necessary — SPRINT PNS (policy stance block)

Coverage determination:

SPRINT PNS coverage: SPRINT PNS (temporary 60-day percutaneous peripheral nerve stimulation) is considered NOT medically necessary.

SPRINT PNS is a temporary 60-day device intended to provide durable symptom relief but is designated not medically necessary by Priority Health.

Priority Health considers most percutaneous electrical nerve stimulation (PENS/PNT) and other percutaneous/auricular neuromodulation approaches experimental or not medically necessary. Except for the pediatric IB‑Stim indication described below, the policy treats auricular neurostimulation devices and PENS/PNT systems as noncovered due to insufficient peer‑reviewed evidence. In addition, TOMAC (Tonic Motor Activation) peroneal nerve stimulation for restless legs syndrome is considered not medically necessary for Priority Health commercial and Medicaid members because available literature does not demonstrate sufficient safety and effectiveness. Finally, auricular neurostimulation devices other than IB‑Stim are categorized as investigational and not medically necessary when used outside the strict IB‑Stim criteria.

Priority Health considers the ReActiv8 restorative neurostimulation system unproven and not medically necessary despite the device having received FDA Premarket Approval. The policy states that the published peer‑reviewed evidence is insufficient to establish efficacy for chronic low back pain and that additional larger comparative studies are needed before coverage will be supported.

The policy designates several procedure codes as Not Medically Necessary when billed for noncovered indications. Examples called out include acupuncture with electrical stimulation (97813, 97814), unlisted nervous system procedures (64999), and the percutaneous peripheral nerve stimulator code (C9807); an additional set of CPT/HCPCS codes also appears in the Not Medically Necessary list and will be excluded from coverage when used for excluded therapies.

SPRINT® PNS (a temporary percutaneous peripheral nerve stimulation system intended for up to 60 days indwelling) is explicitly declared not medically necessary by Priority Health. The policy notes SPRINT’s unique temporary treatment intent but still finds insufficient evidence to support coverage.

Priority Health considers PENS and PNT modalities not medically necessary for any indication, stating there is insufficient evidence in the peer‑reviewed literature to support their safety and effectiveness.

Priority Health determines that TOMAC peroneal nerve stimulation therapy for restless legs syndrome (RLS) is not medically necessary for commercial and Medicaid members due to insufficient evidence demonstrating safety and effectiveness.

Although ReActiv8® received FDA Premarket Approval, Priority Health considers this form of restorative neurostimulation unproven and not medically necessary because the available published evidence does not adequately demonstrate clinical efficacy for the indicated population.

The policy lists multiple CPT/HCPCS codes that are designated Not Medically Necessary for the specified modalities; examples in this list include 0278T, A4541–A4545, E0733, E0734, E0721, E0737, and E0743. Billing these codes for excluded or investigational indications may result in claim denial.

Acupuncture with electrical stimulation codes (97813, 97814), the unlisted nervous system procedure code (64999), and the percutaneous peripheral nerve stimulator code (C9807) are identified in the policy’s Not Medically Necessary list and will be subject to exclusion when billed for noncovered indications.

As reiterated elsewhere in the policy, Priority Health considers SPRINT PNS (temporary 60‑day percutaneous PNS) not medically necessary; this clarification emphasizes that temporary percutaneous PNS devices intended for short‑term implantation are excluded from coverage under the current evidence assessment.

Coding and Billing

Referenced CMS NCDsmixed

NCD 10.2	Transcutaneous Electrical Nerve Stimulation (TENS) for Acute PostOperative Pain
NCD 160.7	Electrical Nerve Stimulators
NCD 160.7.1	Assessing Patient's Suitability for Electrical Nerve Stimulation Therapy
NCD 160.13	Supplies Used in the Delivery of TENS and NMES
NCD 160.27	Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP)

TENS / Electrical stimulation CPT/HCPCSCPT/HCPCS

97014	Application of a modality to one or more areas; electrical stimulation (unattended)
97032	Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes
G0283	Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
A4558	Conductive gel or paste, for use with electrical device (e.g., TENS, NMES), per oz
A4595	Electrical stimulator supplies, 2 lead, per month, (e.g. TENS, NMES)
A4630	Replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient
E0720	Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation
E0730	Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation
E0731	Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric)

Percutaneous electrical nerve field stimulation CPTCPT

64567

Percutaneous electrical nerve field stimulation, cranial nerves, without implantation

Not Medically Necessary CPT/HCPCSCPT/HCPCSNot Covered

0278T	Transcutaneous electrical modulation pain reprocessing (eg, scrambler therapy), each treatment session (includes placement of electrodes)
A4541	Monthly supplies for use of device coded at E0733
A4542	Supplies and accessories for external upper limb tremor stimulator of the peripheral nerves of the wrist
A4543	Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month
A4544	Electrode for external lower extremity nerve stimulator for restless legs syndrome
A4545	Supplies and accessories for external tibial nerve stimulator (e.g., socks, gel pads, electrodes, etc.), needed for one month
E0733	Transcutaneous electrical nerve stimulator for electrical stimulation of the trigeminal nerve
E0734	External upper limb tremor stimulator of the peripheral nerves of the wrist
E0721	Transcutaneous electrical nerve stimulatory, stimulates nerves in the auricular region
E0737	Transcutaneous tibial nerve stimulator, controlled by phone application

1–10 of 11

1/2

TEAS CPT/HCPCSHCPCS

E0765

FDA approved nerve stimulator, with replaceable batteries, for treatment of nausea and vomiting

Covered/Listed HCPCSHCPCS

E0765

FDA approved nerve stimulator, with replaceable batteries, for treatment of nausea and vomiting

PENS/PNT CPT codesCPT

64567

Percutaneous electrical nerve field stimulation, cranial nerves, without implantation

Not Medically Necessary codesmixedNot Covered

97813	Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
97814	Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)
64999	Unlisted procedure, nervous system
C9807	Nerve stimulator, percutaneous, peripheral (e.g., sprint peripheral nerve stimulation system), including electrode and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid medical device for postsurgical pain relief in accordance with section 4135 of the caa, 2023)

Peripheral implantation and generator proceduresCPTCovered

64555	Percutaneous implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve)
64575	Incision for implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve)
64590	Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection
64595	Revision or removal of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, with detachable connection to electrode array (No Auth)

Implantable neurostimulator procedure and supply codesmixedCovered

64596	Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance; initial electrode array
64597	Each additional electrode array (list separately)
64598	Revision or removal of neurostimulator electrode array, peripheral nerve, with integrated neurostimulator
95970	Electronic analysis of implanted neurostimulator pulse generator/transmitter, without programming
95971	Electronic analysis of implanted neurostimulator pulse generator/transmitter; with simple programming
95972	Electronic analysis of implanted neurostimulator pulse generator/transmitter; with complex programming
A4438	Adhesive clip applied to the skin to secure external electrical nerve stimulator controller, each
C1767	Generator, neurostimulator (implantable), nonrechargeable
C1778	Lead, neurostimulator (implantable)
C1787	Patient programmer, neurostimulator

1–10 of 20

1/2

ICD-10 codes that may apply to peripherally implanted nerve stimulatorICD-10

G54.8	Other nerve root and plexus disorders
G54.9	Nerve root and plexus disorder, unspecified
G55	Nerve root and plexus compressions in diseases classified elsewhere
G56.40	Causalgia of upper limb
G56.80	Other specified mononeuropathies
G57.70	Causalgia of lower limb
G58.0	Intercostal neuropathy
G58.7	Mononeuritis multiplex
G58.8	Other specified mononeuropathies
G89.0	Central pain syndrome

1–10 of 20

1/2

Therapeutic trial response threshold

Therapeutic trial response threshold>= 50% reduction in pain during temporary electrode trial prior to permanent implantation

Trial methodTemporary electrode placement to determine therapeutic analgesia

Documentation requirementRecord of ≥50% analgesia during trial must be provided for permanent PNS consideration

Authorization exceptions

Authorization exceptions — No Auth codesCodes 64595 and 95970 are listed with 'No Auth' (no prior authorization required)

Scope'No Auth' designation applies to specific implantation/programming codes as listed in the coding section

Provider actionConfirm 'No Auth' status on claim submission for the listed codes; otherwise obtain prior authorization per policy

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for permanently implanted peripheral nerve stimulators and for other services when specified by the policy or payer rules. When prior authorization is required, providers must submit requests through Priority Health Prism Auth and include documentation demonstrating medical necessity per the policy criteria.

Use Priority Health Prism Authorizations for required services
Failure to obtain required prior authorization may result in denial

Denial Risk

Unproven Device — Denial Risk

Requests for certain peripheral nerve stimulation devices or modalities that Priority Health considers unproven (for example, restorative neurostimulation such as ReActiv8®) will likely be denied as not medically necessary. Individual case review may be considered only with prior plan approval and typically requires review by a Priority Health medical director or clinical pharmacist.

ReActiv8® and similar restorative neurostimulation devices considered unproven and not medically necessary
Individual exception requests require prior plan approval and clinical review

Documentation Required

Prior Authorization / Medical Necessity Documentation

When prior authorization is required, providers must submit documentation demonstrating medical necessity. Documentation should include objective evidence of pathology, prior conservative therapies tried, results of therapeutic trials, psychological assessment when relevant, and any supporting clinical literature (randomized trials, systematic reviews) when available.

Objective evidence (e.g., EMG, imaging) for implanted PNS requests
Documentation of prior conservative therapies (analgesics, physical therapy, local injections)
Psychological assessment and absence of substance addiction where applicable
Provide relevant randomized trials or systematic reviews when available

Documentation Required

Conservative Therapy and Therapeutic Trial Requirements for Implanted PNS

A therapeutic trial demonstrating at least 50% analgesia with a temporary electrode trial is expected prior to permanent peripheral nerve stimulator implantation. For implanted PNS, members must be refractory to conservative therapies (analgesics, physical therapy, local injection) and complete a successful transcutaneous stimulation trial (e.g., two-week trial with ≥50% pain reduction) before consideration of permanent implantation.

Temporary electrode trial with ≥50% pain relief required prior to permanent PNS implantation
Conservative therapy requirement: analgesics, physical therapy, local injection must have been tried and been refractory

Prior Authorization

TENS Initial Trial — Prior Authorization Note

TENS (transcutaneous electrical nerve stimulation) initial trial rules: no prior authorization is required for the first two-month (60-day) trial for commercial and Medicaid members. For Medicare members, rental rules differ — prior authorization may be required from month one for Medicare.

No prior authorization required for initial 2-month TENS trial (commercial and Medicaid)
Medicare: prior authorization/rental rules differ; prior auth required from first month rental for Medicare

Documentation Required

TENS Continuation Documentation

Authorization of TENS beyond the initial two-month trial requires documentation demonstrating clinical benefit. Providers seeking authorization for continuation must show improvement such as increased physical activity, decreased pain, or decreased use of analgesics.

Documentation required for authorization beyond initial 2-month trial: at least two of - increased physical activity; decreased pain; decreased use of analgesics
Continuation requests must include objective evidence of functional improvement or pain reduction

Documentation Required

TENS Trial and Diagnosis Documentation

TENS trial and diagnosis documentation: providers should submit supporting ICD-10 diagnosis codes that align with covered indications and the trial. The policy lists multiple applicable ICD-10 codes for TENS rental/coverage; include diagnosis coding and trial details when requesting continuation or coverage beyond the initial trial.

Include appropriate ICD-10 codes that support TENS use (e.g., G89.21–G89.29, M54.5, M51.36, etc.)
Document initial trial duration, response, and indication when requesting authorization

Billing Rule

Billing — Not Medically Necessary Codes and Billing Rules

Billing and coding: certain CPT/HCPCS codes and supplies are designated Not Medically Necessary and may be denied when billed. Use the listed allowable codes for covered services and avoid billing codes identified as Not Medically Necessary.

Not Medically Necessary codes include (non‑exhaustive): 0278T, A4541–A4545, E0733, E0734, E0721, E0737, E0743, 97813, 97814, 64999, C9807
Covered/commonly billed codes for TENS and PNS include: 97014, 97032, G0283, A4558, A4595, A4630, E0720, E0730, E0731 and implant codes 64555, 64575, 64590, 64595, 64596–64598, 95970–95971

Documentation Required

Supporting Documentation for PNS Requests

Requests for PNS (including novel devices such as SPRINT temporary PNS) should include supporting clinical literature where available. Randomized trials, systematic reviews, and consensus guidelines are helpful to support requests. Note that SPRINT PNS (60-day temporary implantation) is noted in the policy as considered not medically necessary and may be denied despite literature.

Provide randomized trials, systematic reviews, or consensus guideline citations when available
Clarification: SPRINT PNS is considered not medically necessary and is at high risk for denial

Conservative Therapy Requirements Before Advanced Interventions

inv-64: failure of ≥1 conservative therapy — placeholder top-level node (detailed criteria present in source)

Conservative therapy failure (general): For permanently implanted peripheral nerve stimulators, the member must be refractory to one or more conservative therapies including analgesics, physical therapy, or local injection prior to consideration for implantation.failure of >=1 conservative therapy

Requirement includes documentation of prior conservative management.

inv-65: failure of ≥1 conservative therapy — related criteria grouping for multiple device types

Conservative therapy for IB-Stim and implanted PNS: IB-Stim requires failure of at least one form of conservative management (e.g., hypnotherapy, CBT, soluble fiber, probiotic). Permanently implanted PNS requires failure of one or more conservative therapies (analgesics, physical therapy, local injection).failure of >=1 conservative therapy

Document specific therapies tried and durations where available.

inv-66: Failure of conservative therapy before consideration — policy expects conservative therapy before device implantation

Failure of conservative therapy before consideration: For restorative neurostimulation (ReActiv8), documentation should show failure of prior therapy including pain medications and physical therapy and that the patient is not a candidate for spine surgery.

Priority Health considers ReActiv8 unproven and not medically necessary despite FDA PMA; documentation of prior conservative therapy is expected if considered in individual cases.

inv-67: Conservative requirement node (empty-label container) — referenced in inventory

Conservative requirement (container)

Examples of conservative therapies: Analgesics (including appropriate trials of non-opioid analgesics and judicious opioid use where applicable); physical therapy; local injection (e.g., nerve block); cognitive behavioral therapy or hypnotherapy for functional pain syndromes; dietary measures and probiotics for abdominal pain syndromes.
List is illustrative and mirrors conservative therapies referenced across device-specific criteria.

inv-68: Conservative requirement node (empty-label container) — referenced in inventory

Conservative requirement (container 2)

Therapeutic trial requirement: Temporary electrode trial demonstrating >=50% pain reduction prior to permanent PNS implantation.>=50%
Document trial duration and objective measurement of pain relief.
TENS trial requirement: Initial TENS trial of two months without prior authorization for commercial and Medicaid; document response if extending beyond two months.2 months
Medicare rental rules differ (prior auth from month one).

Treatment Duration and Frequency Limits

IB-Stim (auricular neurostimulation) — frequency limitation

IB-Stim coverage limitationOnly one course of auricular neurostimulation treatment will be considered medically necessary

IndicationIB-Stim (NeurAxis) may be considered for pediatric functional abdominal pain when criteria met (age 8-21, Rome IV, conservative therapy failed)

Repeat treatmentsRepeat courses are not supported by peer-reviewed evidence and are considered not medically necessary

SPRINT temporary PNS device indwelling period

Maximum indwelling periodUp to 60 days (SPRINT PNS intended duration)

Device intentTemporary percutaneous stimulator designed to provide durable symptom relief during the 60-day period

Clinical trials referenceSPRINT evaluated in randomized and observational studies with leads indwelling for ~8 weeks

Percutaneous lead treatment period in published studies

Reported average indwelling periodApproximately 57 days reported in retrospective study of chronic shoulder pain

Study methodsPercutaneous leads implanted under ultrasound guidance; average treatment period reported

Clinical implicationPublished series corroborate near-8-week indwelling periods used in practice

Frequency limits for implantation and programming codes

Frequency limits statementNo explicit frequency limits are specified in this section for implantation (64555, 64596) or programming (95971-95972) codes

Coding implicationClaims should follow coding guidance; policy does not set per-member caps for these procedure/programming codes

Provider actionIf prior authorization is required for a procedure, follow Section VII medical necessity review processes

Percutaneous peripheral nerve stimulation (SPRINT PNS)

SPRINT PNS per-treatment limit60-day maximum per treatment episode for temporary percutaneous PNS

Coverage stanceSPRINT PNS is described as intended for up to 60 days but is considered not medically necessary by Priority Health

DocumentationRequests should document device type and intended 60-day duration; anticipate review per policy clarification

Imaging and Procedural Notes

Note

Ultrasound guidance recommended for PNS lead placement

Ultrasound guidance was used in clinical trials for percutaneous lead placement and is recommended/used for PNS lead placement; document imaging guidance when performed.

Trials reported "ultrasound-guided placement of percutaneous fine-wire coiled leads targeting the femoral and sciatic nerves."
Document use of ultrasound guidance in operative/procedure notes when applicable.

Billing Rule

Document imaging guidance when billing 64596

When insertion or replacement of a percutaneous electrode array is performed, include imaging guidance details as appropriate when billing CPT code 64596.

"64596 ... including imaging guidance, when performed; initial electrode array."

Documentation Required

Document procedural details for percutaneous PNS (lead target, duration, imaging)

For percutaneous peripheral nerve stimulation procedures, document procedural details, nerve targets, duration of indwelling leads, and imaging guidance as used in published studies.

Published studies describe nerve targets (e.g., femoral, sciatic), indwelling lead periods (57–60 days), and ultrasound guidance.
Include these procedural specifics in the request/claim when applicable.

Key Definitions

Background: Transcutaneous electrical nerve stimulation (TENS) delivers low‑voltage electrical impulses via skin electrodes to modulate pain through gating mechanisms or endorphin release and may be used in home or clinic settings. TENS devices are described as battery‑powered systems that stimulate nerves at or near the pain site; an initial two‑month trial of TENS for any diagnosis does not require prior authorization, and continuation beyond that trial requires documentation of benefit (at least two of increased activity, decreased pain, or decreased analgesic use).

Definition — TENS

DefinitionTENS: battery-powered device delivering electrical impulses through electrodes placed on the skin at or near the pain site

MechanismsWorks via gating of pain signals and/or increasing endogenous endorphin release

SettingsCan be used in home, physician office, or outpatient clinic settings

Definition — PENS/PNT

DefinitionPENS/PNT: therapies using thin filiform needle electrodes placed percutaneously near a peripheral nerve delivering electrical current from an external pulse generator

Device characteristicsPENS devices are temporary and do not require permanent implantation

Related CPT64567 describes percutaneous electrical nerve field stimulation (cranial) without implantation

Definition — PENFS

DefinitionPENFS: percutaneous electrical nerve field stimulation that targets a field of pain (e.g., auricular cranial nerve branches) rather than a specific nerve

ExampleIB-Stim (NeurAxis) is a PENFS device intended for auricular stimulation to reduce functional abdominal pain

Typical use patternIB-Stim described for up to 120 hours/week for up to 3 consecutive weeks in device labeling

Definition — Peripheral Nerve Stimulation (PNS)

DefinitionPeripheral Nerve Stimulation (PNS): surgical insertion of an electrode along a targeted peripheral nerve connected to a receiver; a temporary electrode trial may precede permanent implantation

Trial thresholdTherapeutic trial demonstrating ≥50% analgesia is required before permanent implantation

Procedures includedImplantation, revision, removal, and device programming are included in peripheral implanted neurostimulator procedures

Definition — PNFS

DefinitionPNFS: subcutaneous leads stimulating small dermal nerve fibers without targeting a precisely identified peripheral nerve

DistinctionDiffers from direct PNS by stimulating a field rather than a specific nerve target

Usage trendIncreased utilization over the past decade as a novel neuromodulation modality

Definition — Restorative neurostimulation (ReActiv8®)

DefinitionRestorative neurostimulation (ReActiv8®): an implantable system for bilateral stimulation of the L2 medial branch to manage chronic low back pain associated with multifidus dysfunction

Regulatory statusFDA granted PMA for ReActiv8® on June 16, 2020

Policy stancePriority Health considers ReActiv8® unproven and not medically necessary due to insufficient evidence

Definition — PENS/PNT (alternate placement)

Alternate placement notePENS/PNT descriptions reference needle-like introducers and placement adjacent to peripheral nerves as an alternative to surface TENS

Therapy natureCombines features of electroacupuncture and TENS with percutaneous electrode delivery

Temporary applicationPENS devices are temporary and external pulse generator supplies current

Definition — Peripheral implanted neurostimulator procedures

DefinitionPeripheral implanted neurostimulator procedures include percutaneous implantation of neurostimulator electrodes, insertion/revision/removal of pulse generators/receivers, and associated programmer/device components

Included codesExamples: 64555, 64596, 64590, 64595 and supply codes listed in implantable neurostimulator group

Imaging guidanceInsertion of electrode array (64596) includes imaging guidance when performed

Definition — SPRINT PNS

DefinitionSPRINT PNS: temporary percutaneous peripheral nerve stimulation device intended for percutaneous implantation for up to 60 days to provide durable symptom relief

Study durationsClinical trials and studies used indwelling periods of ~8 weeks (57-60 days) aligning with intended 60-day use

Coverage stanceAlthough intended for 60 days, SPRINT PNS is considered not medically necessary by Priority Health

Not Covered / Not Medically Necessary Items

Not covered summary: Priority Health excludes coverage for PENS/PNT for any indication, TOMAC for RLS (commercial and Medicaid), and ReActiv8 restorative neurostimulation (implanted) as not medically necessary. The policy also lists specific CPT/HCPCS and miscellaneous codes (for example, 0278T, 97813/97814, 64999, C9807, and several A‑ and E‑codes) that are designated Not Medically Necessary and subject to denial when billed for excluded indications. IB‑Stim remains the single auricular neurostimulation device that may be considered medically necessary under narrow pediatric criteria; all other auricular devices are investigational.