L8696 — Antenna (external) for use with implantable diaphragmatic/phrenic nerve stimulation device, replacement, each
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- Documentation of severe, chronic respiratory failure requiring mechanical ventilation and the specific qualifying diagnosis (alveolar hypoventilation from brainstem disorder OR interruption of neuronal conduction at/above C3) or, for NeuRx, documentation of stable high spinal cord injury.
- Evidence of intact/integrity of the intrathoracic section of the phrenic nerve (e.g., phrenic nerve EMG, nerve conduction studies).
- Evidence diaphragm is stimulable and diaphragmatic function is sufficient to accommodate chronic stimulation (e.g., diaphragm EMG, fluoroscopic demonstration of diaphragm movement with stimulation).
- Baseline estimated pulmonary function test results known or documentation explaining why baseline estimate is likely adequate.
Key Coverage Criteria
- Avery Diaphragm Pacing System (previously Mark IV) is medically necessary as an alternative to invasive mechanical ventilation for an individual with severe, chronic respiratory failure requiring mechanical ventilation for EITHER: alveolar hypoventilation (primary or secondary to a brainstem disorder) OR interruption of neuronal conduction at the upper cervical level, at or above the C3 vertebral level.
- Avery Diaphragm Pacing System when ALL of the following are met: integrity of the intrathoracic section of the phrenic nerve; diaphragmatic function sufficient to accommodate chronic stimulation; baseline estimated pulmonary function test is known, or likely, to be adequate; individual has normal chest anatomy, normal level of consciousness, and the ability to participate in and complete the training and rehabilitation associated with the use of the device.
- NeuRx DPS RA/4 Respiratory Stimulation System is medically necessary when provided in accordance with FDA Humanitarian Device Exemption (HDE) specifications and ALL of the following are met: age 18 years and older; has a stable, high spinal cord injury; has a stimulable diaphragm but lacks control of the diaphragm.
- Candidates for NeuRx (per clinical trial/inclusion criteria) include patients with cervical spinal cord injury dependent on mechanical ventilation who are clinically stable following acute injury, have bilateral phrenic nerve function clinically acceptable (demonstrated by EMG and nerve conduction times), diaphragm movement with stimulation visible under fluoroscopy, clinically acceptable oxygenation on room air (>90% O2 saturation), hemodynamic stability, no medical comorbidities that would int [...]
- Medically necessary to eliminate or reduce the need for mechanical ventilator support in patients with chronic ventilatory insufficiency or failure due to bilateral diaphragmatic paralysis or severe diaphragmatic paresis.
- Severe, chronic respiratory failure requiring an alternative to mechanical ventilation due to upper cervical spinal cord injury at or above the C3 vertebral level.
2 Active Policies
AMBETTER-CP.MP.203 — Diaphragmatic/Phrenic Nerve Stimulation
CIGNA-0391 — Diaphragmatic/Phrenic Nerve Stimulation - (0391)
Related Codes
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