K1020, Non-invasive vagus nerve stimulator
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Prescription from a healthcare provider required to load the device with days of therapy (refill card).
- Clinical documentation supporting the reason for pulse generator removal (e.g., device malfunction, intolerable side effects, signs of infection, or lack of efficacy).
- Providers must reference the most up-to-date CPT manuals and professional coding guidance prior to submission of claims for reimbursement.
- Refer to the applicable state Medicaid manual for any Medicaid coverage provisions that may override this policy.
Key Coverage Criteria
- Adjunctive therapy for medically refractory epilepsy using chronic intermittent stimulation of the left vagus nerve.
- Adjunctive therapy for treatment-resistant major depressive disorder (FDA-approved).
- Diagnosis of focal onset (formerly partial onset) seizures or generalized onset seizures.
- Intractable epilepsy defined by failure of at least one year of adherent therapy with at least two anti-seizure drugs and continued seizures that have a major impact on activities of daily living.
- Member is not a suitable candidate for, is opposed to, or has failed epilepsy surgery.
- Request is for an FDA‑approved VNS device.
1 Active Policy
AMBETTER-CP.MP.12, Vagus Nerve Stimulation
Related Codes
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