C1816, Receiver and/or transmitter, neurostimulator (implantable)
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- Imaging and laboratory/biomarker data used in studies: brain CT or MRI, amyloid PET (e.g., florbetapir), cerebrospinal fluid (CSF) biomarkers (Aβ1-42, total tau, phospho-tau), and APOE ε4 genotyping when reported in trials.
- For some interventional procedures/trials, pre-procedure evaluations included medical/neurological and psychological examinations, depression rating scales (e.g., Montgomery–Asberg Depression Rating Scale), and lumbar puncture with CSF analysis.
- Documentation of prior/concurrent standard therapies (e.g., use of cholinesterase inhibitors and/or memantine) is often recorded in trials and may be relevant when considering investigational add-on therapies.
- None specified in this policy document. (The CPB lists investigational/experimental treatments and codes not covered; it does not define separate documentation requirements for coverage of the listed items.)
- None specified in this document excerpt.
- Electrocardiogram (ECG) results to identify cardiac abnormalities (sinus bradycardia, signs of hypokalemia, arrhythmias) when clinically indicated.
Key Coverage Criteria
- None specified. This Clinical Policy Bulletin addresses experimental treatments for Alzheimer's disease and lists treatments considered experimental and investigational (i.e., not established as effective) for this indication.
- No explicit covered indications are stated in this document. The document discusses potential therapeutic use in the following conditions:
- Alzheimer's disease (AD)
- mild cognitive impairment (MCI)
- amnestic MCI
- pre-clinical AD
20 Active Policies
ANTHEM-CG-MED-79, CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
CIGNA-0391, Diaphragmatic/Phrenic Nerve Stimulation
AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments
AETNA-CPB-0511, Eating Disorders
AETNA-CPB-0614, Huntington's Disease
AETNA-CPB-0707, Headaches: Invasive Procedures
AETNA-CPB-0253, Vocal Cord Paralysis / Insufficiency Treatments
AETNA-CPB-0755, Motor Cortex Stimulation
AETNA-CPB-0362, Spasticity Management
AETNA-CPB-0406, Tinnitus Treatments
AETNA-CPB-0374, Trigeminal Neuralgia: Treatments
AETNA-CPB-0191, Vagus Nerve Stimulation
AMBETTER-CP.MP.203, Diaphragmatic/Phrenic Nerve Stimulation
AMBETTER-CP.MP.12, Vagus Nerve Stimulation
BCBSIL-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions
BCBSIL-SUR712.009, Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation
BCBSMT-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions
BCBSMT-SUR712.009, Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation
BCBSNM-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions
BCBSNM-SUR712.009, Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.