00158
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- The ReActiv8 Implantable Neurostimulation System is consideredmedically necessarywhenallof the following criteria are met:
- Adult (age at least 18 years old);and
- Diagnosis of lumbar multifidus muscle dysfunction;and
- Chronic low-back pain that has lasted longer than 6 months;and
- Chronic low-back pain is non-radicular and non-neuropathic in character, with clinical records indicating that other potential sources of chronic back pain have been ruled out;and
- History of pain on at least half of the days in the previous year;and
1 Active Policy
ANTHEM-SURG.00158 — SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
Related Codes
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