National and state-level analysis of peripheral nerve stimulation reimbursement patterns
4 affiliations
- 1Mayo Clinic Alix School of Medicine, Rochester, USA
- 2Departments of Orthopaedic Surgery and Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
- 3Pain Diagnostics and Interventional Care, Sewickley, PA, USA
- 4Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
Abstract
Background
Peripheral nerve stimulation (PNS) is an increasingly utilized neuromodulation therapy for refractory chronic pain. However, physician reimbursement patterns for PNS procedures under Medicare, Medicaid, and other insurers remain poorly characterized. Because Medicaid reimbursement influences provider participation and patient access - particularly among low-income populations - quantifying these differences may highlight barriers to equitable access to neuromodulation.Objective
To quantify interstate variation in Medicaid reimbursement on an absolute basis and relative to Medicare for common PNS procedures, and to analyze national Medicare utilization and payment trends for these procedures.Methods
State-level Medicaid professional fee reimbursement rates for three common PNS CPT codes (64555: percutaneous lead implantation; 64575: open lead implantation; 64590: pulse generator insertion/replacement) as well as CPT 64553 (percutaneous cranial nerve lead implantation) were compared with corresponding 2026 Medicare Physician Fee Schedule rates. Medicaid rates were extracted from publicly available 2026 state fee schedules and analyzed before and after Medicare Wage Index adjustment. Medicaid-to-Medicare Indices (MMI) and reimbursement differentials normalized by work relative value units (wRVUs) were calculated to characterize the size and consistency of this payer gap across states and procedures. Secondary analyses examined national Medicare utilization and payment trends (2013-2024) using the CMS Physician & Other Practitioners by Geography and Service dataset to assess whether reimbursement patterns aligned with changes in procedural demand over time.Results
Median wage-adjusted Medicaid reimbursement was less than Medicare for all four codes: 32.1% for CPT 64555 (facility setting), 27.3% for CPT 64555 (non-facility setting), 14.0% for CPT 64575 (facility), 19.2% for CPT 64590 (facility), 27.3% for CPT 64590 (non-facility), 26.8% for CPT 64553 (facility), and 36.7% for CPT 64553 (non-facility). Reimbursement fell below Medicare parity in 61.7% to 86.5% of evaluated states depending on code and setting. From 2013 to 2024, Medicare utilization trends diverged by procedure: services, providers, and beneficiaries increased substantially for CPT 64555 and CPT 64590, but decreased for CPT 64575 and CPT 64553, even as average standardized payment rose for all four codes.Conclusions
Medicaid reimbursement for common PNS procedures is consistently lower than Medicare, with largest shortfall and interstate variability differing meaningfully by procedure and site of service. These procedure-specific disparities, alongside divergent utilization trends, suggest that targeted reimbursement adjustments may be needed to mitigate access barriers for Medicaid beneficiaries.
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BibTeX
@article{mizerak2026national,
title = {{National and state-level analysis of peripheral nerve stimulation reimbursement patterns}},
author = {Evan J. Mizerak and Jay Karri and David A. Provenzano and Ryan S. D'Souza},
journal = {Interventional pain medicine},
year = {2026},
month = oct,
doi = {10.1016/j.inpm.2026.100826},
url = {https://europepmc.org/article/PMC/PMC13718633},
note = {CC BY},
}
RIS
TY - JOUR
TI - National and state-level analysis of peripheral nerve stimulation reimbursement patterns
AU - Evan J. Mizerak
AU - Jay Karri
AU - David A. Provenzano
AU - Ryan S. D'Souza
PY - 2026
DA - 2026/10/21
JO - Interventional pain medicine
DO - 10.1016/j.inpm.2026.100826
UR - https://europepmc.org/article/PMC/PMC13718633
AB - Background Peripheral nerve stimulation (PNS) is an increasingly utilized neuromodulation therapy for refractory chronic pain. However, physician reimbursement patterns for PNS procedures under Medicare, Medicaid, and other insurers remain poorly characterized. Because Medicaid reimbursement influences provider participation and patient access - particularly among low-income populations - quantifying these differences may highlight barriers to equitable access to neuromodulation.Objective To quantify interstate variation in Medicaid reimbursement on an absolute basis and relative to Medicare for common PNS procedures, and to analyze national Medicare utilization and payment trends for these procedures.Methods State-level Medicaid professional fee reimbursement rates for three common PNS CPT codes (64555: percutaneous lead implantation; 64575: open lead implantation; 64590: pulse generator insertion/replacement) as well as CPT 64553 (percutaneous cranial nerve lead implantation) were compared with corresponding 2026 Medicare Physician Fee Schedule rates. Medicaid rates were extracted from publicly available 2026 state fee schedules and analyzed before and after Medicare Wage Index adjustment. Medicaid-to-Medicare Indices (MMI) and reimbursement differentials normalized by work relative value units (wRVUs) were calculated to characterize the size and consistency of this payer gap across states and procedures. Secondary analyses examined national Medicare utilization and payment trends (2013-2024) using the CMS Physician & Other Practitioners by Geography and Service dataset to assess whether reimbursement patterns aligned with changes in procedural demand over time.Results Median wage-adjusted Medicaid reimbursement was less than Medicare for all four codes: 32.1% for CPT 64555 (facility setting), 27.3% for CPT 64555 (non-facility setting), 14.0% for CPT 64575 (facility), 19.2% for CPT 64590 (facility), 27.3% for CPT 64590 (non-facility), 26.8% for CPT 64553 (facility), and 36.7% for CPT 64553 (non-facility). Reimbursement fell below Medicare parity in 61.7% to 86.5% of evaluated states depending on code and setting. From 2013 to 2024, Medicare utilization trends diverged by procedure: services, providers, and beneficiaries increased substantially for CPT 64555 and CPT 64590, but decreased for CPT 64575 and CPT 64553, even as average standardized payment rose for all four codes.Conclusions Medicaid reimbursement for common PNS procedures is consistently lower than Medicare, with largest shortfall and interstate variability differing meaningfully by procedure and site of service. These procedure-specific disparities, alongside divergent utilization trends, suggest that targeted reimbursement adjustments may be needed to mitigate access barriers for Medicaid beneficiaries.
SN - 2772-5944
ER -