|MP 7.01.37||Electrophrenic Pacemaker|
|Original Policy Date
|Last Review Status/Date
Reviewed with literature search/1:2006
|Return to Medical Policy Index|
Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.
The electrophrenic pacemaker is an implanted electrode and receiver with a pocket or table-top size external transmitter. The device electrically stimulates the phrenic nerves to contract the diaphragm rhythmically, which causes breathing.
The use of an electrophrenic pacemaker is considered medically necessary for the following patients with permanent, severe hypoventilation caused by brain or high cervical cord lesions:
- Quadriplegia (high C3 or above);
- Central alveolar hypoventilation syndrome.
Electrophrenic pacemakers are considered not medically necessary when:
- Patient can subsist independently of a mechanical respirator;
- Respiratory insufficiency is temporary.
The use of the electrophrenic pacemaker is considered investigational for the following conditions:
- Chronic obstructive pulmonary disease;
- Young children and infants;
- Treatment of hiccups.
Electrophrenic pacemakers are contraindicated in the following situations:
- Pre-operative screening tests do not demonstrate that phrenic nerves, lungs, and diaphragm can sustain ventilation by electrical stimulation;
- Patient has another serious disorder that might affect nerve conduction (e.g., tumors, vascular disease, diabetes, multiple sclerosis, etc.).
No applicable information
A search of the literature was completed through the MEDLINE database for the period of January 1992 through December 2005. No additional studies were identified that focused on the use of electrophrenic stimulation for the treatment of refractory hiccups. Due to the paucity of additional literature published in the last 5 years, this policy is assigned to no further review.
|CPT||64575||Incision for implantation of neurostimulator electrodes; peripheral nerve|
|64585||Revision or removal of peripheral neurostimulator electrodes|
|ICD-9 Procedure||34.85||Implantation of diaphragmatic pacemaker|
|ICD-9 Diagnosis||344.01||C1–C4 Complete quadriplegia|
|344.02||C1–C4 Incomplete quadriplegia|
|348.8||Other conditions of brain|
|Type of Service||Surgical|
|Place of Service||Inpatient|
Stimulation, Electrical, Phrenic Nerve
|3/31/96||Add to Surgery section||New policy|
|7/12/02||Replace policy||Policy reviewed by consensus; new review date only|
|07/17/03||Replace policy||Policy reviewed by consensus; policy unchanged|
|03/15/05||Replace policy||Policy reviewed with literature search; policy unchanged|
|03/7/06||Replace policy||Policy reviewed with literature search; policy unchanged; no further scheduled review|