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MP 7.01.37 Electrophrenic Pacemaker

Medical Policy
Section
Surgery
Original Policy Date
3/31/96
Last Review Status/Date
Reviewed with literature search/1:2006
Issue
1:2006
Return to Medical Policy Index

Disclaimer

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.


Description

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.


Policy

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.


Policy Guidelines

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.).


Benefit Application

No applicable information


Rationale

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.

 

Codes

Number

Description

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 
HCPCS  No Code   
Type of Service  Surgical 
Place of Service  Inpatient 


Index

Electrophrenic Pacemaker
Pacemaker, Electrophrenic
Stimulation, Electrical, Phrenic Nerve


Policy History

Date Action Reason
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


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