L8679 — Implantable neurostimulator, pulse generator, any type
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews.
- For medical necessity clinical coverage criteria for deep brain and responsive cortical stimulation, refer to the InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes.
- When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs.
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews. For FES for lower limb paralysis due to SCI, documentation should demonstrate each of the listed required criteria (exact wording):
Key Coverage Criteria
- Deep brain stimulation is proven and medically necessary for treating the following indications: Dystonia
- Deep brain stimulation is proven and medically necessary for treating the following indications: Essential tremor
- Deep brain stimulation is proven and medically necessary for treating the following indications: Parkinson's disease
- Deep brain stimulation is proven and medically necessary for treating the following indications: Refractory epilepsy for a partial or focal seizure disorder
- Responsive cortical stimulation is proven and medically necessary for treating refractory partial or focal seizure disorder
- Transcutaneous electrical nerve stimulator (TENS) is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Durable Medical Equipment, Transcutaneous Electrical Nerve Stimulation (TENS). [...]
20 Active Policies
AMBETTER-CP.MP.180 — Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
AMBETTER-CP.MP.117 — Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation
AMBETTER-CP.MP.142 — Urinary Incontinence Devices and Treatments
CIGNA-0063 — Headache, Occipital, and/or Trigeminal Neuralgia Treatment - (0063)
CIGNA-GES — Gastric Pacing/Gastric Electrical Stimulation (GES) - (0103)
Related Codes
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