E0735 — Non-invasive vagus nerve stimulator
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- "Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews."
- Documentation of medically refractory epileptic seizures (drug-resistant epilepsy), e.g., evidence that the patient has failed two or more trials of single or combination antiepileptic drug therapy or had intolerable side effects (names/duration/response to AEDs).
- Documentation that the individual is not a candidate for epilepsy surgery, has failed epilepsy surgery, or explicitly refuses epilepsy surgery after a Shared Decision Making discussion (record of the shared decision making discussion and rationale).
- Documentation confirming no history of left or bilateral cervical vagotomy (to demonstrate absence of this FDA-identified contraindication).
Key Coverage Criteria
- Implantable vagus nerve stimulators are proven and medically necessary for treating epilepsy in individuals with all of the following:
- Medically refractory epileptic seizures with failure of two or more trials of single or combination antiepileptic drug therapy or intolerable side effects of antiepileptic drug therapy; and
- The individual is not a candidate for epilepsy surgery, has failed epilepsy surgery, or refuses epilepsy surgery after Shared Decision Making discussion; and
- No history of left or bilateral cervical vagotomy. The U.S. Food and Drug Administration (FDA) identifies a history of left or bilateral cervical vagotomy as a contraindication to vagus nerve stimulation.
- Temporal artery biopsy — CPT 37609: "Ligation or biopsy, temporal artery [covered for biopsy to rule out temporal arteritis]" (ICD-10: M31.6 Other giant cell arteritis [suspected temporal arteritis] listed as an ICD-10 code covered if selection criteria are met).
- Botulinum toxin: "Botulinum toxin (however, botulinum toxin is considered medically necessary for chronic migraine headache when criteria in CPB 0113 - Botulinum Toxin are met)" (i.e., botulinum toxin is covered for chronic migraine only when CPB 0113 criteria are satisfied).
8 Active Policies
HUMANA-VAGUS-NERVE-STIMULATION-MA — Vagus Nerve Stimulation - Medicare Advantage
AETNA-CPB-0191 — Vagus Nerve Stimulation
AETNA-CPB-0707 — Headaches: Invasive Procedures
ANTHEM-CG-SURG-120 — CG-SURG-120 Vagus Nerve Stimulation
ANTHEM-CG-MED-100 — CG-MED-100 Surface Electrical Stimulation Devices for Headache and Migraine
Related Codes
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