L8688 — Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews.
- For medical necessity clinical coverage criteria for deep brain and responsive cortical stimulation, refer to the InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes.
- When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs.
- General statement: "Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the guidelines titled Medical Records Documentation Used for Reviews."
Key Coverage Criteria
- Deep brain stimulation is proven and medically necessary for treating the following indications: Dystonia
- Deep brain stimulation is proven and medically necessary for treating the following indications: Essential tremor
- Deep brain stimulation is proven and medically necessary for treating the following indications: Parkinson's disease
- Deep brain stimulation is proven and medically necessary for treating the following indications: Refractory epilepsy for a partial or focal seizure disorder
- Responsive cortical stimulation is proven and medically necessary for treating refractory partial or focal seizure disorder
- - Improvement in reported symptoms of 50% or greater in response to a screening trial of Sacral Nerve Stimulation
20 Active Policies
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
AMBETTER-CP.MP.12 — Vagus Nerve Stimulation
Related Codes
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