National and state-level analysis of peripheral nerve stimulation reimbursement patterns

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.

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.

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.

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.

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.