61892
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
14.63
Facility
$1096.22
Non-Facility
$1096.22
Documentation Required
- Clinical documentation confirming patient age (≥18) and diagnosis of focal epilepsy.
- Seizure frequency records showing an average of ≥3 disabling seizures per month over the prior 3 months.
- Medication history documenting trials of ≥2 appropriate antiepileptic drugs with therapeutic doses and reasons for failure/intolerance.
- Neurophysiologic and imaging documentation (EEG, video-EEG monitoring, MRI, etc.) demonstrating 1–2 well-localized seizure foci.
Key Coverage Criteria
- Responsive neurostimulation (RNS) for the treatment of refractory focal epilepsy.
- Adults (≥18 years) with a diagnosis of focal seizures and 1 or 2 well-localized seizure foci.
- Average of ≥3 disabling seizures per month (e.g., motor focal, complex focal, or secondary generalized) over the prior 3 months.
- Refractory to medical therapy, defined as failure of ≥2 appropriate antiepileptic drugs at therapeutic doses.
- Not candidates for focal resective epilepsy surgery (for example, epileptic focus near eloquent cortex or bilateral temporal epilepsy).
- No contraindications to responsive neurostimulation device placement.
5 Active Policies
BCBSIL-SUR712.039 — Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
BCBSMT-SUR712.039 — Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
BCBSNM-SUR712.039 — Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
BCBSOK-SUR712.039 — Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
SUR712.039 — Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
Related Codes
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