Does 61864 require prior authorization?

No, 61864 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 61864?

Medicare facility rate: $259.19. Non-facility rate: $259.19. Work RVU: 4.38.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

4.38

Facility

$259.19

Non-Facility

$259.19

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews.
For medical necessity clinical coverage criteria for deep brain and responsive cortical stimulation, refer to the InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes.
When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs.
Imaging and laboratory/biomarker data used in studies: brain CT or MRI, amyloid PET (e.g., florbetapir), cerebrospinal fluid (CSF) biomarkers (Aβ1-42, total tau, phospho-tau), and APOE ε4 genotyping when reported in trials.

Deep brain stimulation is proven and medically necessary for treating the following indications: Dystonia
Deep brain stimulation is proven and medically necessary for treating the following indications: Essential tremor
Deep brain stimulation is proven and medically necessary for treating the following indications: Parkinson's disease
Deep brain stimulation is proven and medically necessary for treating the following indications: Refractory epilepsy for a partial or focal seizure disorder
Responsive cortical stimulation is proven and medically necessary for treating refractory partial or focal seizure disorder
None specified. This Clinical Policy Bulletin addresses experimental treatments for Alzheimer's disease and lists treatments considered experimental and investigational (i.e., not established as effective) for this indication.

AETNA-CPB-0406 — Tinnitus Treatments

AETNA-CPB-0614 — Huntington's Disease

AETNA-CPB-0755 — Motor Cortex Stimulation

AETNA-CPB-0788 — Alzheimer's Disease: Experimental Treatments

UMR-POL-UMR-deep-brain-cortical-stimulation — Deep Brain and Cortical Stimulation

Ask Verity about documentation requirements, denial risks, or coverage in your state.