Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain Form

Effective Date

12/28/2023

Last Reviewed

11/09/2023

Original Document

  Reference



This document addresses implantable peripheral nerve stimulation devices as a treatment for pain. These devices are temporarily or permanently implanted and provide direct electrical stimulation to peripheral nerves.

Note: For information on similar technologies used to treat pain, please see the following related documents:

  • CG-DME-04 Electrical Nerve Stimulation, Transcutaneous, Percutaneous
  • DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
  • SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)

Position Statement

Investigational and Not Medically Necessary:

Implantable peripheral nerve stimulation devices are considered investigational and not medically necessary for all indications including, but not limited to, treatment of acute and chronic pain.