L8684, Radiofrequency transmitter (external) for use with implantable sacral root
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation that a neurological cause for the pain cannot be detected (clinical/neurological evaluation).
- Documentation of failure of prior conservative treatments, specifically: high-fiber diet; withdrawal of drugs that cause constipation (e.g., calcium channel blockers, narcotics) or diarrhea (e.g., antibiotics, quinidine, theophylline); perineal strengthening exercises; rectal massage; warm baths; and drug therapy (e.g., muscle relaxants, non-narcotic analgesics, and sedatives).
- Documentation that no underlying disease has been revealed by anorectal examination or by manometry, radiology, or endoscopy (reports/results from anorectal exam, manometry, radiologic studies, endoscopy as applicable).
- Treatment records documenting number of sessions, session duration (to ensure ≤ three 60-minute sessions within a 10-day period for medical necessity), settings used, and patient tolerance/response.
Key Coverage Criteria
- Aetna considers biofeedback medically necessary for members with refractory levator syndrome when criteria listed above are met. (See CPB 0132 - Biofeedback).
- CPT codes covered if selection criteria are met: 97014 (electrical stimulation unattended), 97032 (electrical stimulation, manual, each 15 minutes).
- HCPCS code covered if selection criteria are met: E0746 (Electromyography (EMG), biofeedback device).
- ICD-10 codes covered if selection criteria are met: K59.4 (Anal spasm [proctalgia fugax]) and K62.89 (Other specified diseases of anus and rectum [chronic anal pain syndrome] [levator syndrome or chronic anal pain syndrome]).
- Biofeedback is medically necessary for members with refractory levator syndrome when the same criteria listed for HVPGS are met. (See CPB 0132 - Biofeedback.)
- High-voltage pulsed electrogalvanic stimulation (HVPGS) is medically necessary for members with refractory levator syndrome (also known as proctalgia fugax, chronic anal pain syndrome) when ALL the following criteria are met: a neurological cause for the pain can not be detected; member has failed prior conservative treatments (high-fiber diet, withdrawal of drugs that cause constipation [e.g., calcium channel blockers, narcotics] or diarrhea [e.g., antibiotics, quinidine, theophylline], perinea [...]
9 Active Policies
ANTHEM-CG-SURG-95, CG-SURG-95 Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence
AETNA-CPB-0679, Levator Syndrome Treatments
AMBETTER-CP.MP.137, Fecal Incontinence Treatments
AMBETTER-CP.MP.142, Urinary Incontinence Devices and Treatments
BCBSIL-SUR710.018, Sacral Nerve Neuromodulation/Stimulation
Related Codes
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