A4541, Monthly supplies for use of device coded at e0733
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
- Documentation that non-epileptic attacks (e.g., cardiogenic syncope, psychogenic seizures) have been ruled out.
- Comprehensive presurgical evaluation documentation (inferred requirement): detailed seizure history, prior anti‑seizure medication trials and failures, seizure frequency and type.
- Electroencephalography (EEG) data including scalp EEG and, when applicable, invasive/subdural recordings — documentation of seizure focus localization (inferred from multiple EEG and invasive monitoring citations).
- Neuroimaging: high‑quality MRI with epilepsy protocol; when applicable diffusion tensor imaging (DTI), MRI thermometry for LITT, and correlation of MRI with clinical data (inferred from DTI and MRI‑guided therapy citations).
Key Coverage Criteria
- Implantable vagus nerve stimulators are proven and medically necessary for treating epilepsy in individuals who have medically refractory seizures with failure of two or more trials of antiseizure drugs (or intolerable AED effects), are not candidates for epilepsy surgery (or have failed/refuse after shared decision making), and have no history of left or bilateral cervical vagotomy.
- Transection of corpus callosum (callosotomy) — CPT 61541, covered if selection criteria are met
- Cerebral hemispherectomy when all selection criteria are met, including members with unilateral multi-focal epilepsy associated with infantile hemiplegia (especially in hemimegalencephaly and Sturge-Weber disease).
- Corpus callosotomy when all selection criteria are met, including members with focal to bilateral seizures (formerly known as secondarily generalized seizures).
- Temporal lobectomy (including selective amygdalohippocampectomy) when all selection criteria are met, including members with focal impaired awareness seizures (formerly known as complex partial seizures) of temporal or extra-temporal origin.
- Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) (e.g., NeuroBlate, Visualase) as an alternative to standard surgery where criteria in section A. on epilepsy surgery are met.
8 Active Policies
UHC-POL-vagus-nerve-stimulation, Vagus and External Trigeminal Nerve Stimulation
AETNA-CPB-0394, Epilepsy Surgery
AETNA-CPB-0078, Learning Disabilities, Dyslexia, and Vision
AETNA-CPB-0374, Trigeminal Neuralgia: Treatments
REGENCE-DME83.14, External Trigeminal Nerve Stimulation for the Treatment of Attention Deficit Hyperactivity Disorder
Related Codes
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