C9807 — Nerve stimulator, percutaneous, peripheral (e.g., sprint peripheral nerve stimulation system), including electrode and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the caa, 2023)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without 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
6 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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