L8687, Implantable neurostimulator pulse generator, dual array, rechargeable, includes
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium 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.
- 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.
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.
- 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.
- 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:
20 Active Policies
CIGNA-0391, Diaphragmatic/Phrenic 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-sacral-nerve-stimulation, Sacral Nerve Stimulation for Urinary and Fecal Indications
UHC-POL-vagus-nerve-stimulation, Vagus and External Trigeminal Nerve Stimulation
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-0378, NeuroControl Freehand System
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.40, Gastric Electrical Stimulation
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
Related Codes
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