E0757
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Refractory to two (2) or more antiepileptic medications;and
- Unilateral or bilateral deep brain stimulation is consideredmedically necessaryfor individuals with Parkinson’s disease when the following criteria have been met:
- A minimal score of 30 points on the motor portion of the Unified Parkinson’s Disease Rating Scale (UPDRS) when the individual has been without medication for 12 hours;and
- Either of the following:Motor complications of therapy that cannot be controlled pharmacologically;orTremor from Parkinson’s disease cannot be controlled pharmacologically.
- Motor complications of therapy that cannot be controlled pharmacologically;or
- Tremor from Parkinson’s disease cannot be controlled pharmacologically.
2 Active Policies
ANTHEM-SURG.00026 — SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
ANTHEM-SURG.00010 — SURG.00010 Treatments for Urinary Incontinence
Related Codes
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