25316
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
12.58
Facility
$850.72
Non-Facility
$850.72
Documentation Required
- Evidence that member has use of their shoulder, upper arm and elbow (clinical documentation).
- Documentation of adequate range of motion with forearm and hand muscles that respond to stimulation with electrical impulses (testing/clinical notes).
- Documentation establishing neurological stability by means of serial neurological examinations over a period of 3 to 6 months that do not show progression of signs and symptoms referable to the area of injury, OR serial imaging of the spine that excludes the presence of a progressive lesion.
- Documentation of skeletal maturity.
Key Coverage Criteria
- Aetna considers the NeuroControl Freehand System medically necessary for members with paralyzed hand(s) who meet all of the following criteria:
- Member must have use of their shoulder, upper arm and elbow;
- Member must have adequate range of motion with forearm and hand muscles that respond to stimulation with electrical impulses;
- Neurological stability is established by means of serial neurological examinations over a period of 3 to 6 months that do not show progression of signs and symptoms referable to the area of injury, or serial imaging of the spine that excludes the presence of a progressive lesion.
- Appropriate candidates for the NeuroControl Freehand System must have use of their shoulder, upper arm, and elbow; they may or may not have use of their wrist, and limited use of their hands.
- The patient must have adequate range of motion with forearm and hand muscles that respond to stimulation with electrical impulses.
2 Active Policies
AETNA-CPB-0378 — NeuroControl Freehand System
AETNA-CPB-0244 — Skin and Soft Tissue Substitutes
Related Codes
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