C9254, Injection, lacosamide, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Diagnosis documentation: clinical diagnosis of diabetic neuropathy (DN) should be based on at least 2 of the following 5: signs; symptoms; quantitative sensory testing; nerve conduction study; autonomic testing.
- Use of validated instruments and examinations: DN4 questionnaire and clinical findings (type of pain, time of occurrence, abnormal sensations) are recommended for diagnosing painful diabetic neuropathy (PDN).
- For surgical decompression candidate selection in published series: symptomatic somatosensory neuropathy (pain, burning, tingling, numbness) with pre-operative neurosensory testing (e.g., computer-assisted neurosensory testing or pressure-specified sensory device) confirming elevated nerve threshold levels and axonal degeneration.
- For SCS patient selection (from trial eligibility criteria): refractory PDN (symptoms ≥1 year) not responding to conventional therapy; lower limb pain intensity ≥5 on a 10-cm VAS; prior trial of gabapentinoids and at least one other analgesic class; BMI ≤45 kg/m2; HbA1c ≤10%; daily morphine equivalents ≤120 mg; medically appropriate for the procedure.
Key Coverage Criteria
- Diabetes mellitus with neurological complications (ICD-10 codes E08.40-E08.49, E09.40-E09.49, E10.40-E10.49, E11.40-E11.49, E13.40-E13.49) as indications listed in the CPB.
- Percutaneous electrical stimulation for the treatment of members with diabetic neuropathy who failed to adequately respond to conventional treatments including anti-convulsants (especially pregabalin), anti-depressants (e.g., amitriptyline, and duloxetine), opioids (e.g., morphine sulphate and tramadol), and other pharmacological agents (e.g., capsaicin and isosorbide dinitrate spray).
- Dorsal column stimulation (DCS) for members with diabetic peripheral neuropathy who meet criteria listed in CPB 0194 - Spinal Cord Stimulation.
- Surgical decompression may be considered medically necessary for entrapment syndromes even though the person has the concomitant diagnosis of diabetic neuropathy. (footnote)
- Amitriptyline, capsaicin, duloxetine, gabapentin, isosorbide dinitrate spray, opioids (e.g., morphine sulfate, and tramadol), valproate, and venlafaxine are probably effective and should be considered for the treatment of painful DN (Level B).
- Percutaneous electrical nerve stimulation should be considered for the treatment of painful DN (Level B). The recommended duration for electrical stimulation is 3 to 4 weeks.
1 Active Policy
AETNA-CPB-0729, Diabetic Neuropathy: Selected Treatments
Related Codes
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