61885
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
5.90
Facility
$557.46
Non-Facility
$557.46
Documentation Required
- 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.
- "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."
Key Coverage Criteria
- 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
- Implantable vagus nerve stimulators are proven and medically necessary for treating epilepsy in individuals with all of the following:
20 Active Policies
AMBETTER-CP.MP.12 — Vagus Nerve Stimulation
AETNA-CPB-0191 — Vagus Nerve Stimulation
AETNA-CPB-0374 — Trigeminal Neuralgia: Treatments
AETNA-CPB-0406 — Tinnitus Treatments
AETNA-CPB-0788 — Alzheimer's Disease: Experimental Treatments
Related Codes
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