E0765 — Fda approved nerve stimulator, for treatment of nausea and vomiting
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- No explicit medical-record documentation requirements, ICD-10 diagnoses, frequency limits, or prior authorization criteria are specified in the provided document text.
- The document repeatedly notes the need for larger, rigorous trials and therefore implies that documentation of diagnosis, prior therapies, and rationale for use would be important, but no formal documentation checklist or required records are specified in the excerpt.
- Prescription documentation: device must be the prescription version (prescription ReliefBand or PrimaBella) when device coverage is being requested.
- Clinical documentation that the patient's nausea and vomiting is unresponsive to antiemetics and other conservative therapies for: post‑operative nausea and chemotherapy‑induced nausea (i.e., documentation of trials of appropriate antiemetic therapy and other conservative treatments and their failure).
Key Coverage Criteria
- The ReliefBand is available by prescription for the treatment of chemotherapy-induced nausea and vomiting (chemotherapy-induced NV).
- The ReliefBand is available by prescription for the treatment of post-operative nausea and vomiting (PONV).
- The ReliefBand is available over-the-counter for the treatment of motion sickness.
- Prescription-version ReliefBand devices for the treatment of chemotherapy-induced nausea that is unresponsive to antiemetics and other conservative therapies.
- Prescription-version ReliefBand devices for the treatment of post-operative nausea that is unresponsive to antiemetics and other conservative therapies.
- Prescription-version PrimaBella or ReliefBand devices for treatment of hyperemesis gravidarum that is unresponsive to other conservative medical therapy (e.g., change in diet, ginger capsules, vitamin B6).
3 Active Policies
AETNA-CPB-0676 — Electrical Stimulation for Nausea, Vomiting and Motion Sickness (PrimaBella and ReliefBand) and Other Selected Indications
ANTHEM-DME.00011 — DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
REGENCE-SUR111 — Gastric Electrical Stimulation
Related Codes
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