A4540, Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- When making coverage determinations, review the member's benefit contract or Summary Plan Description (SPD) for coverage definitions, exclusions, and benefit limitations (e.g., dollar or duration caps).
Key Coverage Criteria
- Covered indications: For treating pain due to malignancy involving the head and neck, (1) injection of local anesthetics and/or steroids used as greater occipital nerve blocks (GONBs) and (2) occipital nerve ablation (destruction by neurolytic agent).
- Initial use of the Nerivio®remote electrical neuromodulation (REN) device for the treatment of migraine is consideredmedically necessaryin individuals who meet ALL of the following criteria:
- Eight years of age or older;and
- Six-month history of headaches that meet International Classification of Headache Disorders (ICHD 3-beta) diagnostic criteria for migraine with or without aura;and
- Meets one of the following two criteria:Nerivio is used to treat acute migraine;orNerivio is used to prevent migraine for individuals with 6 to 24 headache days (defined as a calendar day with headache regardless of severity or duration) per 28-day period in each of the 3 months preceding use of Nerivio.
- Nerivio is used to treat acute migraine;or
10 Active Policies
ANTHEM-DME.00011, DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
ANTHEM-CG-MED-100, CG-MED-100 Surface Electrical Stimulation Devices for Headache and Migraine
UHC-POL-occipital-neuralgia-headache-treatment, Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache)
BCBSIL-SUR701.046, Remote Electrical Neuromodulation for Migraines
Related Codes
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