E0735, Non-invasive vagus nerve stimulator
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Trigeminal/occipital radiofrequency or nerve ablation/neurectomy: documentation of diagnostic nerve blocks demonstrating temporary relief, prior conservative treatments attempted and failed, technique details, and baseline/ongoing outcome measures.
- No documentation requirements are stated in this excerpt (bibliography only).
- nVNS (gammaCore): diagnosis of episodic cluster headache for acute indication (adult patients), record of device prescription and patient training, documentation of attacks treated and response rates, and for prophylactic/adjunctive use in cCH documentation of prior treatments and rationale for adjunctive therapy (PREVA-like paradigms).
- VTA-DBS (and other invasive neuromodulation like ONS/DBS): documentation of medically refractory chronic cluster headache with failure of multiple adequate trials of standard therapies, prior trial/failure of occipital nerve stimulation (if applicable), multidisciplinary team evaluation (headache neurologist and functional neurosurgeon), baseline headache frequency/severity, and detailed informed consent describing investigational status and risks.
Key Coverage Criteria
- Implantable vagus nerve stimulators are proven and medically necessary for treating epilepsy in individuals who have medically refractory seizures with failure of two or more trials of antiseizure drugs (or intolerable AED effects), are not candidates for epilepsy surgery (or have failed/refuse after shared decision making), and have no history of left or bilateral cervical vagotomy.
- 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).
- Occipital nerve block (greater occipital nerve) — CPT 64405: "Injection, anesthetic agent; greater occipital nerve" — listed as "CPT codes covered if selection criteria are met" for occipital neuralgia.
- "Occipital nerve block is allowable only for diagnosing occipital neuralgia" (explicit policy statement).
- ICD-10 codes explicitly listed as covered if selection criteria are met: "M31.6 Other giant cell arteritis [suspected temporal arteritis]" (general section) and "M54.81 Occipital neuralgia" (occipital neuralgia section).
8 Active Policies
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
UHC-POL-vagus-nerve-stimulation, Vagus and External Trigeminal Nerve Stimulation
AETNA-CPB-0707, Headaches: Invasive Procedures
AETNA-CPB-0191, Vagus Nerve Stimulation
Related Codes
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