L8695 — External recharging system for battery (external) for use with implantable neurostimulator, replacement only
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high 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, refer to the InterQual CP: Procedures, Spinal Cord Stimulator (SCS) Insertion.
- Documentation that the procedure is consistent with FDA labeled indications, contraindications, warnings, and precautions.
- When requesting replacement battery/generator, documentation that the existing battery/generator is malfunctioning, cannot be repaired, and is no longer under warranty.
Key Coverage Criteria
- Implanted electrical spinal cord stimulators are proven and medically necessary for treating the following conditions in certain circumstances, when performed according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions: Complex regional pain syndrome (CRPS).
- Implanted electrical spinal cord stimulators are proven and medically necessary for treating the following conditions in certain circumstances, when performed according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions: Painful lower limb diabetic neuropathy.
- Implanted electrical spinal cord stimulators are proven and medically necessary for treating the following conditions in certain circumstances, when performed according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions: Failed back surgery syndrome.
- Dorsal root ganglion (DRG) stimulation is proven and medically necessary for treating refractory complex regional pain syndrome (CRPS I, CRPS II) in certain circumstances when performed according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions.
- 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
AMBETTER-CP.MP.203 — Diaphragmatic/Phrenic Nerve Stimulation
AETNA-CPB-0011 — Electrical Stimulation for Pain
AETNA-CPB-0191 — Vagus Nerve Stimulation
AETNA-CPB-0253 — Vocal Cord Paralysis / Insufficiency Treatments
AETNA-CPB-0362 — Spasticity Management
Related Codes
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