C1827, Generator, neurostimulator (implantable), non-rechargeable, with implantable
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation that the patient does not have a left or bilateral cervical vagotomy (Appendix exclusion: "VNS can not be used in persons with left or bilateral cervical vagotomy").
- Documentation that patient is not exposed to contraindicated procedures (e.g., diathermy) and screening for contraindications (text: "Contraindications include vagotomy and diathermy").
- For paired VNS in stroke rehabilitation (Vivistim): documentation that VNS will be used "along with post-stroke rehabilitation" for moderate-to-severe upper extremity motor deficits associated with chronic ischemic stroke (FDA summary: "indicated to be used, along with post-stroke rehabilitation, in individuals who have had ischemic stroke to reduce deficiencies in upper limb and extremity motor function").
Key Coverage Criteria
- HCPCS codes covered if selection criteria are met: L8689 External recharging system for battery (internal) for use with implanted neurostimulator, replacement only
- Aetna considers vagus nerve electrical stimulators medically necessary durable medical equipment (DME) for shortening the duration or reducing the severity of seizures in members with focal seizures (formerly known as partial onset seizures) who remain refractory to optimal anti-epileptic medications and/or surgical intervention (such as a lesionectomy or medial temporal lobectomy), or who have debilitating side effects from anti-epileptic medications, and who have no history of a bilateral or l [...]
- Electronic analysis of an implanted neurostimulator pulse generator system for vagus nerve stimulation is considered medically necessary when criteria are met.
- Aetna considers vagus nerve electrical stimulators medically necessary durable medical equipment (DME) for the treatment of Lennox-Gastaut syndrome in members who remain refractory to optimal anti-epileptic medications, and/or surgical intervention (such as a corpus callosotomy or lesional epilepsy surgery), or who have debilitating side effects from anti-epileptic medications, and who have no history of a bilateral or left cervical vagotomy.
- Aetna considers replacement/revision of a vagus nerve therapy system/handheld magnet medically necessary if the original system/magnet met criteria as medically necessary and is no longer under warranty and cannot be repaired.
- CPT/HCPCS codes listed as 'covered if selection criteria are met' (examples in policy): CPT 61885, 64553, 64568, 64569, 64570, 95970, 95976; HCPCS C1767, C1778, C1816, C1883, L8680-L8695 (see policy table for full list).
4 Active Policies
HUMANA-OBSTRUCTIVE-SLEEP-APNEA-AND-OTHER-SLEEP-RELATED-BREATHING-DISORDERS-SURGICAL-TREATMENTS-MA, Obstructive Sleep Apnea and Other Sleep Related Breathing Disorders Surgical Treatments
AETNA-CPB-0191, Vagus Nerve Stimulation
REGENCE-SUR74, Vagus Nerve Stimulation
UHCMA-POL-UHC_MA-neurologic-services-procedures, Neurologic Services and Procedures
Related Codes
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