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Implanted Electrical Stimulator for Spinal Cord ...

Impla nted Electr ica l Stimula tor for Spina l Cor d Page 1 of 4 UnitedHea lthca r e Commer cia l Medica l Policy Effective 11/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. UnitedHealthcare Commercial Med i ca l P ol i cy Implanted Electrical Stimulator for Spinal cord Policy Number: 2021T0567R Effective Date: Nov e mber 1, 2021 Instructions for Use Table of Contents Page Coverage Rationale .. 1 Documentation 1 Applicable Codes .. 3 Food and Drug Administration .. 3 Policy History/Revision 4 Instructions for Use .. 4 Coverage Rationale Implanted Electrical Spinal cord stimulators, including high-frequency Spinal cord stimulators and burst Spinal cord stimulators are proven and medically necessary for treating the following indications: Complex regional pain syndrome (CRPS) Failed back surgery syndrome Implanted Electrical Spinal cord stimulators are unproven and not medically necessary for treating the following indications: Diabetic Neuropathy Refractory angina

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service descrbi ed by the code is a covered or non -covered health service.

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  Electrical, Spinal, Cord, Implanted, Stimulator, Implanted electrical stimulator for spinal cord

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