103 Form

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Medical Policy
Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 103 BCBSA Reference Number: 1.01.31 (For Plan internal use only) NCD/LCD: N/A Related Policies
Transcutaneous Electrical Nerve Stimulation, #003 Percutaneous and Subcutaneous Tibial Nerve Stimulation, #583 Peripheral Subcutaneous Field Stimulation; #513 Percutaneous Electrical Nerve Stimulation, Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy, #172 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Peripheral nerve stimulation as a treatment for chronic pain is considered INVESTIGATIONAL.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service.

CPT Codes / HCPCS Codes / ICD Codes
Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

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Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT Codes There is no specific CPT code for this service. Description Peripheral Neuropathic Chronic Pain Chronic, noncancer pain is responsible for a high burden of illness and can be defined as persistent pain that lasts for more than 3 months.1, Chronic pain of peripheral origin may be caused by damage to peripheral nerves impacting the upper and lower extremities.

Peripheral Nerve Stimulation Peripheral nerve stimulation (PNS) has been used to treat chronic pain. It is a percutaneous system consisting of leads, electrodes, and a pulse transmitter that delivers electrical impulses to peripheral nerves. Leads are placed using ultrasound guidance and can be placed for temporary or permanent use in an outpatient procedure.

Summary
Description Peripheral nerve stimulation (PNS) is a percutaneous system consisting of leads, electrodes, and a pulse transmitter that delivers electrical impulses to peripheral nerves. Leads are placed using ultrasound guidance and can be placed for temporary or permanent use in an outpatient procedure.

Summary of Evidence For individuals who have peripheral, neuropathic, chronic pain who receive peripheral nerve stimulation (PNS), the evidence includes several randomized controlled trials (RCTs). Relevant outcomes are symptoms, medication use, and quality of life. Statistically significant differences in responder rates were reported in the RCTs ranging from 38% to 88% in the treatment groups and 0% to 24% in the control groups. Overall limitations of the current evidence includes small sample sizes, heterogeneous patient populations, high attrition rates, and lack of long-term follow-up data. Additional evidence from RCTs with larger sample sizes and longer durations of comparative data are necessary to assess the efficacy and durability of PNS. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action 9/2025 Annual policy review. Policy updated with literature review through April 23, 2025; references added. Policy statement unchanged. 11/2024 New medical policy describing investigational indications. PNS to treat chronic pain of peripheral nerve origin is considered investigational. Effective 11/1/2024. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

1. Hardt J, Jacobsen C, Goldberg J, et al. Prevalence of chronic pain in a representative sample in the United States. Pain Med. Oct 2008; 9(7): 803-12. PMID 18346058

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2. Dworkin RH, Turk DC, Farrar JT, et al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain. Jan 2005; 113(1-2): 9-19. PMID 15621359
3. Dworkin RH, Turk DC, Wyrwich KW, et al. Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. J Pain. Feb 2008; 9(2): 105-21. PMID 18055266
4. Char S, Jin MY, Francio VT, et al. Implantable Peripheral Nerve Stimulation for Peripheral Neuropathic Pain: A Systematic Review of Prospective Studies. Biomedicines. Oct 17, 2022; 10(10). PMID 36289867
5. Deer T, Pope J, Benyamin R, et al. Prospective, Multicenter, Randomized, Double-Blinded, Partial Crossover Study to Assess the Safety and Efficacy of the Novel Neuromodulation System in the Treatment of Patients with Chronic Pain of Peripheral Nerve Origin. Neuromodulation. Jan 2016; 19(1): 91-100. PMID 26799373
6. Gilmore C, Ilfeld B, Rosenow J, et al. Percutaneous peripheral nerve stimulation for the treatment of chronic neuropathic postamputation pain: a multicenter, randomized, placebo-controlled trial. Reg Anesth Pain Med. Jun 2019; 44(6): 637-645. PMID 30954936
7. Gilmore CA, Ilfeld BM, Rosenow JM, et al. Percutaneous 60-day peripheral nerve stimulation implant provides sustained relief of chronic pain following amputation: 12-month follow-up of a randomized, double-blind, placebo-controlled trial. Reg Anesth Pain Med. Nov 17 2019. PMID 31740443
8. Ilfeld BM, Plunkett A, Vijjeswarapu AM, et al. Percutaneous Peripheral Nerve Stimulation (Neuromodulation) for Postoperative Pain: A Randomized, Sham-controlled Pilot Study. Anesthesiology. Jul 01 2021; 135(1): 95-110. PMID 33856424
9. Goree JH, Grant SA, Dickerson DM, et al. Randomized Placebo-Controlled Trial of 60-Day Percutaneous Peripheral Nerve Stimulation Treatment Indicates Relief of Persistent Postoperative Pain, and Improved Function After Knee Replacement. Neuromodulation. Jul 2024; 27(5): 847-861. PMID 38739062
10. Hatheway J, Hersel A, Song J, et al. Clinical study of a micro-implantable pulse generator for the treatment of peripheral neuropathic pain: 3-month and 6-month results from the COMFORT- randomised controlled trial. Reg Anesth Pain Med. May 31 2024. PMID 38821535
11. Hatheway J, Hersel A, Engle M, et al. Clinical study of a micro-implantable pulse generator for the treatment of peripheral neuropathic pain: 12-month results from the COMFORT-randomized controlled trial. Reg Anesth Pain Med. Nov 20 2024. PMID 39572166
12. Langford B, D'Souza RS, Pingree M, et al. Treatment of Ulnar Neuropathic Pain with Peripheral Nerve Stimulation: Two Case Reports. Pain Med. May 02 2023; 24(5): 566-569. PMID 36271859
13. Oswald J, Shahi V, Chakravarthy KV. Prospective case series on the use of peripheral nerve stimulation for focal mononeuropathy treatment. Pain Manag. Nov 2019; 9(6): 551-558. PMID 31686589
14. Deer TR, Levy RM, Rosenfeld EL. Prospective clinical study of a new implantable peripheral nerve stimulation device to treat chronic pain. Clin J Pain. Jun 2010; 26(5): 359-72. PMID 20473041
15. Luna D, Hettie G, Pirrotta L, et al. Real-world long-term outcomes of peripheral nerve stimulation: a prospective observational study. Pain Manag. Jan 2025; 15(1): 37-44. PMID 39834252
16. Strand N, D'Souza RS, Hagedorn JM, et al. Evidence-Based Clinical Guidelines from the American Society of Pain and Neuroscience for the Use of Implantable Peripheral Nerve Stimulation in the Treatment of Chronic Pain. J Pain Res. 2022; 15: 2483-2504. PMID 36039168
17. Centers for Medicare & Medicaid. National Coverage Determination (NCD) for Peripheral Nerve Stimulation (L34328). 2019; https://www.cms.gov/medicare-coverage- database/view/lcd.aspx?LCDId=34328. Accessed June 13, 2025.