A4438, Adhesive clip applied to the skin to secure external electrical nerve
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Claims may require medical records documentation to assess whether the member meets the clinical criteria for coverage; however, documentation does not guarantee coverage.
- Medical Records Documentation Used for Reviews
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
8 Active Policies
ANTHEM-SURG.00158, SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
UHC-POL-electrical-stimulation-treatment-pain-muscle-rehabilitation, Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
BCBSIL-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions
BCBSMT-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions
Related Codes
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