Imaging and fusion decisions should follow guideline-based conservative care principles: for adults <50 years without systemic signs or symptoms, routine advanced imaging is not indicated and symptomatic therapy without imaging is appropriate. Advanced imaging (eg, MRI/CT) should be reserved for patients who are considering surgery or when systemic disease is suspected. For radiculopathy, MRI is appropriate if bilateral symptoms, urinary retention, or failure to improve after a conservative course (typically 4–6 weeks) are present. Documented correlation between imaging findings and the level(s) of clinical symptoms is required when fusion or decompression is proposed.

Within the code and coverage listings included in these chunks there are no additional explicit exclusion statements beyond those articulated elsewhere in the policy documents. Providers should therefore rely on the specific exclusion sections and device- or indication-level not-covered statements present elsewhere in the policy when determining noncoverage.

Deep brain stimulation (DBS) is explicitly listed as NOT covered for obsessive‑compulsive disorder. The policy also treats DBS for secondary dystonias (other than those associated with Parkinson disease or essential tremor) as investigational due to insufficient evidence: most DBS dystonia trials focus on primary dystonia and include too few secondary dystonia patients to establish effectiveness.

The evidence base for DBS in patients with secondary dystonia is limited: published studies are predominantly small case series with few patients and therefore do not permit conclusions regarding effectiveness in secondary dystonia. This limitation underlies the investigational stance for these patients.

Patients with severe, limiting comorbidities (for example, Class III–IV angina pectoris, Stage III or higher congestive heart failure, or debilitating arthritis) are considered contraindicated for DBS procedures. Such comorbidities should be documented and may preclude implantation.

The StaXx XD Expandable Device is not covered for interbody fusion because it is not FDA‑approved for that indication. The policy notes that SelectHealth covers interbody devices only for FDA‑approved indications, and use of a device outside its approved indications meets the plan definition of experimental/investigational and will be denied.

Contraindications to intrathecal baclofen (pump) therapy include hypersensitivity to baclofen and general surgical contraindications (eg, sepsis, coagulopathy). Documentation of these contraindications must be present as they preclude trial or permanent pump placement.

Surgical techniques performed primarily to treat migraine (for example, PFO closure, corrugator/frontalis muscle resection, and intranasal 'contact point' surgery) are classified as experimental/investigational and are NOT covered under the Commercial plan and CHIP, based on inconclusive evidence of safety and efficacy.

Posterior dynamic deformity correction devices (eg, MIDC/ApiFix) and anterior vertebral body tethering (eg, The Tether) for progressive adolescent idiopathic scoliosis are not covered. The policy states there is insufficient clinical data demonstrating improved outcomes or long‑term safety, so these device‑based scoliosis correction approaches are considered experimental/investigational.

SelectHealth considers peripheral nerve stimulation (PNS) for occipital neuralgia and chronic headaches investigational and not covered under the Commercial plan. The policy cites small, unblinded studies, limited randomized data with mixed or inconclusive primary endpoints, modest average effects in meta-analysis, and notable device complications (eg, lead migration, infection) as the rationale for noncoverage.

Peripheral nerve stimulation for the indications discussed is specifically listed in the policy as Not Covered: Investigational/Experimental/Unproven. Providers should expect noncoverage for these indications and should document alternative care plans if proposed.

The American Academy of Neurology guideline (2016) advises against using QEEG measures such as the theta/beta power ratio or frontal beta power to replace a standard clinical evaluation for ADHD. The policy summarizes that QEEG applications remain largely formative and insufficient to support routine clinical use for the indications reviewed.

Medicare coverage is governed by CMS determinations; when a CMS NCD/LCD exists it controls Medicare coverage. Community Care (Medicaid) policies typically align with state Medicaid (eg, Utah Medicaid) and may use InterQual; if CMS or state determinations are not available, SelectHealth commercial policy may apply. Providers must verify plan‑specific coverage and prior authorization requirements in each case.

SelectHealth does NOT cover sphenopalatine ganglion (SPG) blocks for any indication under the Commercial plan (including acute or chronic headaches and CRPS). The policy cites limited and mixed evidence from small trials and pilot studies that suggest possible short‑term effects but lack consistent durable clinically significant benefit; therefore SPG blockade is considered investigational and not covered.

Provocative discography is not recommended as a diagnostic procedure for chronic non‑radicular low back pain. The policy references guideline guidance that discourages routine use of provocative discography in this context.

Within the chunks cited there are no explicit standalone statements labelled 'not medically necessary.' Coverage determinations in this policy are presented as covered, not covered (investigational/experimental), or as specific device/indication exclusions rather than using that phrase in these excerpts.

Several investigational uses for DBS are described in the policy context where evidence is limited (small case series, limited RCT data) and safety concerns have been raised. The policy highlights that for indications such as treatment‑resistant OCD and certain dystonias, the literature is preliminary, effect durability and safety are uncertain, and larger randomized trials are needed before routine coverage can be supported.

For treatment‑resistant obsessive‑compulsive disorder, DBS evidence consists mainly of small series and a single small randomized sham‑controlled trial; the policy notes the low strength of evidence and concerns about adverse events, concluding that current evidence is insufficient to prove efficacy and safety for routine coverage of DBS in OCD.

The policy states that procedures categorized as investigational, experimental, or unproven for a given indication are not covered. This includes interventions for which available trials are small, uncontrolled, or demonstrate modest effects with important device‑related safety issues; such services may be denied as not covered.

Evidence limitations and safety concerns are repeatedly cited as the basis for investigational or not‑covered designations: small sample sizes, lack of blinding or control groups, modest effect sizes in pooled analyses, and device complications such as lead migration and infection are specifically referenced as reasons to classify a therapy as investigational.

QEEG (brain mapping) services for the indications discussed are listed as Not Covered: Investigational/Experimental/Unproven. The policy notes the formative state of the literature and guideline cautions (eg, AAN guidance) against substituting QEEG metrics for standard clinical evaluation.

The policy concludes that current evidence is insufficient to establish consistent, durable benefit for SPG blockade in migraine and headache disorders. Although small pilot studies report short‑term relief in some patients, larger controlled trials with durable clinical endpoints are lacking; accordingly SPG blockade is considered investigational and not covered for Commercial/CHIP members.

Background: This document set comprises multiple neurosurgical device and procedure policies. The Table of Contents includes Vagus Nerve Stimulation (Policy #186) along with related policies covering DBS, PNS, intrathecal pumps, spinal fusion, SPG blocks, and others; SelectHealth applies evidence reviews and external guidelines to inform coverage decisions across these topics.