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
- Claims may require medical records documentation to assess whether the member meets the clinical criteria for coverage; however, documentation does not guarantee coverage.
- Daily symptom measurements during temporary stimulation sessions (as done in Abell et al).
- Gastric emptying testing (solid GET) performed before and after temporary GES (Shine et al).
- Electrogastrography (EGG) recordings (cutaneous and/or mucosal) at baseline and after temporary GES, including measures of frequency, amplitude, frequency-amplitude ratio, and propagation; specifically baseline mucosal EGG recorded following mucosal lead placement but before stimulator activation (recommended by Abell et al).
- Definition of response to temporary stimulation when used as a predictive test (example used in Corvinus et al: response defined as a 50% decrease of baseline GCSI).
- Documentation of prior medical management and medically refractory status (e.g., ongoing use and failure of prokinetic and antiemetic medications as reported in trials).
Key Coverage Criteria
- Deep brain stimulation is proven and medically necessary for treating dystonia, essential tremor, Parkinson disease, and refractory epilepsy for a partial or focal seizure disorder.
- Covered indication: Implanted electrical spinal cord stimulators are medically necessary for CRPS, painful diabetic neuropathy, and failed back surgery syndrome when performed per FDA-labeled indications and cautions.
- Removable oral appliances are proven and medically necessary for treating obstructive sleep apnea (OSA) when a sleep study confirms diagnosis and prior evaluation has occurred.
- Covered indications: For treating pain due to malignancy involving the head and neck, (1) injection of local anesthetics and/or steroids used as greater occipital nerve blocks (GONBs) and (2) occipital nerve ablation (destruction by neurolytic agent).
- Sacral Nerve Stimulation (neurostimulation) screening trial is proven and medically necessary for treating urinary voiding dysfunction when all the following criteria are met: Lower urinary tract symptoms, as indicated by one or more of the following: Overactive bladder symptoms, Urge Incontinence, Nonobstructive urinary retention; Bladder capacity ≥100 mL; No neurologic cause; No bladder outlet obstruction; Symptoms refractory to conservative care; Individual capable of operating the device.
- Implantable vagus nerve stimulators are proven and medically necessary for treating epilepsy in individuals who have medically refractory seizures with failure of two or more trials of antiseizure drugs (or intolerable AED effects), are not candidates for epilepsy surgery (or have failed/refuse after shared decision making), and have no history of left or bilateral cervical vagotomy.
20 Active Policies
ANTHEM-SURG.00158, SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
ANTHEM-SURG.00112, SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)
ANTHEM-CG-SURG-70, CG-SURG-70 Gastric Electrical Stimulation
ANTHEM-CG-SURG-95, CG-SURG-95 Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence
ANTHEM-CG-SURG-120, CG-SURG-120 Vagus Nerve Stimulation
UHC-POL-deep-brain-cortical-stimulation, Deep Brain and Cortical Stimulation
UHC-POL-electrical-stimulation-treatment-pain-muscle-rehabilitation, Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
UHC-POL-implanted-electrical-stimulator-spinal-cord, Implanted Electrical Stimulator for the Spinal Cord
UHC-POL-obstructive-sleep-apnea-treatment, Obstructive and Central Sleep Apnea Treatment
UHC-POL-occipital-neuralgia-headache-treatment, Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache)
UHC-POL-sacral-nerve-stimulation, Sacral Nerve Stimulation for Urinary and Fecal Indications
UHC-POL-vagus-nerve-stimulation, Vagus and External Trigeminal Nerve Stimulation
AETNA-CPB-0678, Gastric Pacing / Electrical Stimulation and Gastroesophageal Per Oral Endoscopic Myotomy
AETNA-CPB-0707, Headaches: Invasive Procedures
AETNA-CPB-0362, Spasticity Management
AMBETTER-CP.MP.40, Gastric Electrical Stimulation
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
ANTHEM-SURG.00026, SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
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