C9807, Nerve stimulator, percutaneous, peripheral (e.g., sprint peripheral nerve
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Key Coverage Criteria
- The ReActiv8 Implantable Neurostimulation System is consideredmedically necessarywhenallof the following criteria are met:
- Adult (age at least 18 years old);and
- Diagnosis of lumbar multifidus muscle dysfunction;and
- Chronic low-back pain that has lasted longer than 6 months;and
- Chronic low-back pain is non-radicular and non-neuropathic in character, with clinical records indicating that other potential sources of chronic back pain have been ruled out;and
- History of pain on at least half of the days in the previous year;and
10 Active Policies
ANTHEM-SURG.00158, SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
BCBSIL-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions
BCBSMT-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions
BCBSNM-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions
BCBSOK-MED205.042
Related Codes
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