Provider Briefing: Peripheral Nerve Stimulation (PNS)

Target CPT: 64555 (Percutaneous implantation of neurostimulator electrode array; peripheral nerve)
Plan Year: 2026
Payer Focus: Major Commercial (e.g., Blue Shield, Cigna, Molina) & Medicare Advantage

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1. Code & Policy Identification

• Primary CPT: 64555 – Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve).
• Associated Codes:
  • 64590/64596: Insertion of pulse generator (IPG) or integrated stimulator.
  • 64585: Revision or removal of peripheral neurostimulator electrode array.
• Payer Policy Reference: Typically found under "Implantable Peripheral Nerve Stimulation for Chronic Pain" (e.g., Blue Shield Policy 1.01.31 or Molina MCP-321).

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2. Authorization Status

• Prior Authorization (PA): REQUIRED for all elective percutaneous trials and permanent implantations.
• Audit Risk: High. Post-payment audits frequently target the "Trial Phase" (64555) to ensure the 50% pain reduction threshold was met before the permanent IPG (64590) was billed.

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3. The Documentation Checklist

To meet 2026 Medical Necessity, the SOAP note must explicitly document:

1. Chronic Pain Duration & Severity: Documentation of refractory, non-malignant pain persisting for at least 3–6 months that is severe enough to interfere with activities of daily living (ADLs).
2. Failure of Conservative Therapy: Evidence of failure, contraindication, or intolerance to at least two of the following for a minimum of 4–6 weeks:
   • Pharmacotherapy (NSAIDs, anticonvulsants, or antidepressants).
   • Physical Therapy (must include specific dates and functional outcomes).
   • Interventional procedures (e.g., nerve blocks or trigger point injections).
3. Psychological Clearance: A formal evaluation by a licensed mental health professional (Psychologist/Psychiatrist) clearing the patient for a permanent implant, ensuring no untreated substance abuse or cognitive issues that would impede device management.

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4. Denial Red Flags

• The "Step Therapy" Trap: Denials occur if the note says "Patient failed PT" without specifying when and why (e.g., "Completed 6 weeks of PT ending 12/2025 with no improvement in VAS score").
• Experimental Exclusions: Many 2026 policies exclude PNS for Headaches (Migraine, Cluster) or Fibromyalgia, labeling them as "Investigational."
• Contraindication Exclusion: Automatic denial if the patient has an active systemic infection or a pre-existing implanted device (like a pacemaker) that has not been cleared for interference.

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5. Clinical Action Plan

Use these SmartPhrases to ensure your documentation is "Audit-Proof":

Clinical Element	Recommended SmartPhrase / Documentation Text
Conservative Failure	"Patient has failed a 6-week course of conservative management including [Medication Name] and supervised Physical Therapy (Dates: MM/YY to MM/YY). Pain remains [X/10] with significant functional deficit in [Specific Activity]."
Trial Success (Post-Trial)	"During the 7-day percutaneous trial (CPT 64555), the patient reported a [X]% reduction in pain and a documented improvement in [Activity, e.g., walking distance/sleep quality], meeting the >50% threshold for permanent implantation."
Functional Assessment	"Baseline [Oswestry/DASH] score is [Score]. Patient is unable to perform [Specific ADL] due to peripheral nerve distribution pain. PNS is indicated to restore functional capacity."

Auditor’s Tip: For 2026, payers are increasingly looking for Validated Functional Scales (Oswestry, DASH, or WOMAC). Simply stating "patient feels better" is no longer sufficient for reimbursement.

Yes, for the 2026 plan year, payers have become more granular regarding which peripheral nerves are considered "medically necessary" versus "investigational." Approval is highly dependent on the nerve location and the associated diagnosis.

1. High-Approval Locations (Medically Necessary)

These nerves are generally approved when documented for chronic, refractory neuropathic pain or post-traumatic/post-surgical pain.

• Lower Extremity:
  • Femoral & Sciatic Nerves: Often approved for chronic knee or leg pain following failed total joint arthroplasty.
  • Tibial & Peroneal Nerves: Approved for chronic foot/ankle pain or peripheral neuropathy (excluding diabetic neuropathy in some plans).
• Upper Extremity:
  • Ulnar, Median, & Radial Nerves: Approved for complex regional pain syndrome (CRPS) or post-traumatic nerve injury.
  • Suprascapular Nerve: Frequently approved for chronic shoulder pain refractory to injections and physical therapy.
• Trunk:
  • Medial Branch of Dorsal Rami: Specifically approved for multifidus muscle dysfunction causing chronic low back pain (e.g., using the ReActiv8 system).

2. Low-Approval / "Investigational" Locations (High Denial Risk)

Payers often label these as "Experimental/Investigational" for 2026, leading to automatic denials regardless of the trial's success.

• Occipital Nerve: Most payers (e.g., Aetna, Cigna) still consider Occipital Nerve Stimulation (ONS) investigational for migraines and cluster headaches.
• Supraorbital/Trigeminal Nerves: Almost universally denied for the treatment of headaches or facial pain.
• Pudendal Nerve: Often denied for pelvic pain due to "insufficient long-term evidence."
• Vagus Nerve: While FDA-approved for other conditions, it is not covered under CPT 64555 for chronic pain management.

3. The "Sacral" Distinction

• CPT 64555 explicitly excludes the Sacral Nerve.
• If you are targeting the sacral nerve for pelvic floor dysfunction or incontinence, you must use CPT 64561. Using 64555 for a sacral target is a common coding error that triggers immediate audits.

Clinical Documentation Tip for Approval

To increase the likelihood of approval for "borderline" nerves (like the intercostal or ilioinguinal nerves), the documentation must include:

1. Diagnostic Nerve Block Success: Proof that a temporary block of that specific nerve resulted in >50% pain relief.
2. Specific Nerve Mapping: A clear description of the nerve's sensory distribution matching the patient's pain pattern.
3. Device Specificity: Mentioning the FDA-cleared indication for the specific system being used (e.g., "SPRINT" or "Nalu") as it relates to that nerve.