L8681, Patient programmer (external) for use with implantable programmable
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Imaging and laboratory/biomarker data used in studies: brain CT or MRI, amyloid PET (e.g., florbetapir), cerebrospinal fluid (CSF) biomarkers (Aβ1-42, total tau, phospho-tau), and APOE ε4 genotyping when reported in trials.
- For some interventional procedures/trials, pre-procedure evaluations included medical/neurological and psychological examinations, depression rating scales (e.g., Montgomery–Asberg Depression Rating Scale), and lumbar puncture with CSF analysis.
- Documentation of prior/concurrent standard therapies (e.g., use of cholinesterase inhibitors and/or memantine) is often recorded in trials and may be relevant when considering investigational add-on therapies.
- None specified in this policy document. (The CPB lists investigational/experimental treatments and codes not covered; it does not define separate documentation requirements for coverage of the listed items.)
- None specified in this document excerpt.
- Trigeminal/occipital radiofrequency or nerve ablation/neurectomy: documentation of diagnostic nerve blocks demonstrating temporary relief, prior conservative treatments attempted and failed, technique details, and baseline/ongoing outcome measures.
Key Coverage Criteria
- None specified. This Clinical Policy Bulletin addresses experimental treatments for Alzheimer's disease and lists treatments considered experimental and investigational (i.e., not established as effective) for this indication.
- No explicit covered indications are stated in this document. The document discusses potential therapeutic use in the following conditions:
- Alzheimer's disease (AD)
- mild cognitive impairment (MCI)
- amnestic MCI
- pre-clinical AD
20 Active Policies
ANTHEM-SURG.00129, SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
ANTHEM-SURG.00158, SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments
AETNA-CPB-0707, Headaches: Invasive Procedures
AETNA-CPB-0253, Vocal Cord Paralysis / Insufficiency Treatments
AETNA-CPB-0755, Motor Cortex Stimulation
AETNA-CPB-0406, Tinnitus Treatments
AETNA-CPB-0374, Trigeminal Neuralgia: Treatments
AETNA-CPB-0191, Vagus Nerve Stimulation
AMBETTER-CP.MP.203, Diaphragmatic/Phrenic Nerve Stimulation
AMBETTER-CP.MP.137, Fecal Incontinence Treatments
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
AMBETTER-CP.MP.12, Vagus Nerve Stimulation
SUR712.033, Occipital Nerve Stimulation
BCBSIL-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions
BCBSIL-SUR712.033, Occipital Nerve Stimulation
BCBSIL-SUR710.018, Sacral Nerve Neuromodulation/Stimulation
BCBSMT-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions
Related Codes
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