Does L8678 require prior authorization?

No, L8678 does not require prior authorization (high confidence). Code is covered without prior authorization.

Verity

`L8678`, Electrical stimulator supplies (external) for use with implantable

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Documentation Required

Claims must be supported by medical record documentation demonstrating that the service meets the LCD L39543 indications and limitations and general CMS medical necessity requirements.
Claims may require medical records documentation to assess whether the member meets the clinical criteria for coverage; however, documentation does not guarantee coverage.
No other explicit documentation requirements, prior-authorization criteria, ICD-10 diagnoses, frequency limits, or billing/coding instructions are provided in this document excerpt.
If 4 TENS leads are ordered for a 4-lead TENS unit, "the medical record must document why 2 leads are insufficient to meet the member's needs."
Before implanting the ReActiv8 device, "multifudus muscle atrophy and weakness must be shown using magnetic resonance imaging (MRI) or during a physical examination using the prone instability test." (Documentation requirement for candidates for implantation.)
For TENS supplies (HCPCS A4595): documentation must justify initial provision and for ongoing supplies/rental DME there must be information in the member's medical record to support that the item continues to be used by the member and remains medically necessary.

Key Coverage Criteria

Services for sacral nerve stimulation are covered only when they meet all indications specified in Local Coverage Determination L39543 for treatment of urinary and/or fecal incontinence.
Coverage requires compliance with general CMS medical necessity requirements and any applicable National Coverage Determinations (NCDs) and Medicare payment rules.
PENS (ICD-10 codes covered if selection criteria are met): M79.2 Neuralgia and neuritis, unspecified [neuropathic pain]
Transcutaneous Electrical Nerve Stimulators (TENS) medically necessary when used as an adjunct or as an alternative to the use of drugs either in the treatment of acute post-operative pain in the first 30 days after surgery, or for certain types of chronic, intractable pain not adequately responsive to other methods of treatment including, as appropriate, physical therapy and pharmacotherapy.
When TENS is used for acute post-operative or chronic intractable pain, initial medically necessary use is for a trial period of at least 1 month but not to exceed 2 months, monitored by the physician to determine effectiveness.
Form-fitting conductive garment medically necessary DME only when it has been approved for marketing by the FDA, has been prescribed by a doctor for delivering TENS for one of the medically necessary indications listed above, and any of the following criteria is met: the member cannot manage without the conductive garment due to large area or number of sites to be stimulated and frequent delivery is required; or the member has a medical need for rehabilitation strengthening following an injury w [...]

20 Active Policies

PALMETTO-JJ-L39543, Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence

PALMETTO-JM-L39543, Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence

UHC-POL-electrical-stimulation-treatment-pain-muscle-rehabilitation, Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation

AETNA-CPB-0011, Peripheral Electrical Nerve Stimulation for Pain

AMBETTER-CP.MP.117, Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation

BCBSIL-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions

BCBSMT-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions

BCBSNM-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions

BCBSOK-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions

REGENCE-SUR111, Gastric Electrical Stimulation

ANTHEM-SURG.00158, SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

REGENCE-SUR174, Occipital Nerve Stimulation

REGENCE-SUR216, Responsive Neurostimulation

REGENCE-SUR134, Sacral Nerve Neuromodulation (Stimulation) for Pelvic Floor Dysfunction

REGENCE-SUR74, Vagus Nerve Stimulation

UMR-POL-UMR-electrical-stimulation-treatment-pain-muscle-rehabilitation, Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation

SUREST-POL-SUREST-electrical-stimulation-treatment-pain-muscle-rehabilitation, Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation

REGENCE-SUR45a, Spinal Cord and Dorsal Root Ganglion Stimulation

REGENCE-SUR205, Implantable Peripheral Nerve Stimulation and Peripheral Subcutaneous Field Stimulation

A59332, Billing and Coding: Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence

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L8678, Electrical stimulator supplies (external) for use with implantable