BlueCross BlueShield of Tennessee Medical Policy Manual

Peripheral Subcutaneous Field Stimulation for the Treatment of Pain

DESCRIPTION

Peripheral subcutaneous field stimulation (PSFS) is a form of neuromodulation intended to treat chronic neuropathic pain. Applications of PSFS being evaluated are craniofacial stimulation for headache and migraine, craniofacial pain, or occipital neuralgia. PSFS is also being investigated for low back, neck, and shoulder pain, inguinal and pelvic pain, thoracic pain, abdominal pain, fibromyalgia and postherpetic neuralgia. With this method, leads are placed subcutaneously within the area of maximal pain with the objective of stimulating the region of affected nerves, cutaneous afferents or the dermatomal distribution of the nerves, which then converge back on the spinal cord. The mechanism of action in PSFS is unknown. There are no FDA devices approved for this use. PSFS is an off-label use of spinal cord stimulation devices that have been FDA approved.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION  

Prospective controlled trials comparing peripheral subcutaneous field stimulation with placebo or alternative treatment modalities are needed to determine the efficacy of this treatment for chronic pain. Currently the evidence is insufficient to determine the effects of the technology on health outcomes.

SOURCES

BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2018). Peripheral subcutaneous field stimulation (7.01.139). Retrieved May 21, 2018 from BlueWeb. (7 articles and/ or guidelines reviewed)

Eldabe, S., Taylor, R., Goossens, S., Bouche, B., G├╝ltuna, I., Green, C., et al. (2018). A randomized controlled trial of subcutaneous nerve stimulation for back pain due to failed back surgery syndrome: the SubQStim study. Neuromodulation, doi: 10.111/ner.12784. [Epub ahead of print]

Kloimstein, H., Likar, R., Kern, M., Neuhold, J., Cada, M., Loning, N., et al. (2014). Peripheral nerve field stimulation (PNFS) in chronic low back pain: a prospective multicenter study. Neuromodulation, 17 (2), 180-187. Abstract retrieved May 21, 2018 from PubMed database.

National Institute for Health and Care Excellence. (2013, March). Interventional procedural guidance: Peripheral nerve-field stimulation for chronic low back pain. Retrieved April 30, 2013 http://www.nice.org.uk.

Verrills, P., Rose, R., Mitchell, B., Vivian, D., & Barnard, A. (2014). Peripheral nerve field stimulation for chronic headache: 60 cases and long-term follow-up. Neuromodulation, 17 (1), 54-59. Abstract retrieved May 21, 2018 from PubMed database.

ORIGINAL EFFECTIVE DATE:  3/1980

MOST RECENT REVIEW DATE:  5/9/2019

ID_BA

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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