C1823, Generator, neurostimulator (implantable), non-rechargeable, with transvenous
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Polysomnography (PSG) results demonstrating baseline AHI and follow-up AHI to document treatment effect.
- Clinical documentation of CSA diagnosis and etiology consistent with trial population (as applicable).
- Polysomnography (PSG) report documenting AHI, CAI, and OAI values meeting the criteria (AHI >20; CAI >50% of apneas and >30 central events; OAI <20% of AHI)
- For 30 days prior to baseline testing: documentation of no hospitalizations for illness, no use of breathing mask–based therapy, and stable medications/therapies
Key Coverage Criteria
- Diaphragmatic/Phrenic StimulationDiaphragmatic/phrenic nerve stimulation with an FDA-approved device is consideredmedically necessaryas an alternative to invasive mechanical ventilation for individuals who are 18 years of age or older when ALL of the following criteria are met:The individual has ventilatory failure from stable, high spinal cord injuryorventilatory failure from central alveolar hypoventilation syndrome;andThe individual cannot breathe spontaneously for 4 continuous hours or more [...]
- The individual has ventilatory failure from stable, high spinal cord injuryorventilatory failure from central alveolar hypoventilation syndrome;and
- The individual cannot breathe spontaneously for 4 continuous hours or more without use of a mechanical ventilator;and
- Diaphragm movement with stimulation is visible under fluoroscopy;and
- Stimulation of the diaphragm either directly or through the phrenic nerve results in sufficient muscle activity to accommodate independent breathing without the support of a ventilator for at least 4 continuous hours a day;and
- Individual has normal chest anatomy, a normal level of consciousness, and has the ability to participate in and complete the training and rehabilitation associated with the use of the device;and
7 Active Policies
ANTHEM-CG-MED-79, CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
SUR701.042, Phrenic Nerve Stimulation for Central Sleep Apnea
BCBSIL-SUR701.042, Phrenic Nerve Stimulation for Central Sleep Apnea
BCBSMT-SUR701.042, Phrenic Nerve Stimulation for Central Sleep Apnea
BCBSNM-SUR701.042, Phrenic Nerve Stimulation for Central Sleep Apnea
Related Codes
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