A4542, Supplies and accessories for external upper limb tremor stimulator of the
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
- A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; for WOPD items the supplier must have a signed SWO prior to delivery.
- A treating practitioner clinical evaluation (in-person or Medicare-approved telehealth) must be documented prior to initiating therapy.
- Document the diagnosis of essential tremor using the applicable Group 1 ICD-10 code(s) as referenced in the LCD-related Policy Article.
- Document baseline BF-ADL scores showing >= 3 on at least one eating/drinking/self-care/writing item and document follow-up BF-ADL demonstrating a 1-point improvement in any such item at re-evaluation.
Key Coverage Criteria
- The beneficiary has a clinical evaluation (in-person or Medicare-approved telehealth) by the treating practitioner prior to receiving an external upper limb tremor stimulator (E0734).
- The beneficiary has a diagnosis of essential tremor (ET) as documented using an applicable Group 1 ICD-10 code per the LCD-related Policy Article.
- The beneficiary is age 18 years or older.
- The beneficiary has no contraindications to external upper limb tremor stimulator therapy as determined by the treating practitioner.
- The external upper limb tremor stimulator is prescribed to treat the beneficiary's dominant upper limb.
- Baseline tremor severity shows a Bain & Findley Tremor ADL (BF-ADL) score >= 3 on at least one item for eating, drinking, self-care, or writing.
3 Active Policies
ANTHEM-DME.00049, DME.00049 External Upper Limb Stimulation for the Treatment of Tremors
L39591, External Upper Limb Tremor Stimulator Therapy
REGENCE-DME83.05, Threshold Electrical Stimulation as a Treatment of Motor Disorders
Related Codes
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