L8683, Radiofrequency transmitter (external) for use with implantable neurostimulator
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium 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.
- No other explicit documentation requirements, prior-authorization criteria, ICD-10 diagnoses, frequency limits, or billing/coding instructions are provided in this document excerpt.
Key Coverage Criteria
- 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.
- 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
20 Active Policies
ANTHEM-SURG.00026, SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
ANTHEM-SURG.00158, SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
ANTHEM-CG-MED-79, CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
CIGNA-0391, Diaphragmatic/Phrenic Nerve Stimulation
UHC-POL-vagus-nerve-stimulation, Vagus and External Trigeminal Nerve Stimulation
AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments
AETNA-CPB-0011, Peripheral Electrical Nerve Stimulation for Pain
AETNA-CPB-0614, Huntington's Disease
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.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
HUMANA-NERVE-STIMULATION-FOR-URINARY-INCONTINENCE-MA, Nerve Stimulation for Urinary Incontinence
Related Codes
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