CG-SURG-120 Vagus Nerve Stimulation

This policy addresses implantation of vagus nerve stimulation (VNS) devices and associated services (electronic analysis and replacement/revision). VNS is medically necessary for individuals with medically and surgically refractory seizures who have failed more than one antiepileptic drug regimen due to persistent seizures or intolerable side effects and have failed or are not candidates for resective epilepsy surgery; analysis and replacement/revision are covered when the original implantation met these criteria. Implantation, analysis, or replacement/revision are not covered when criteria are not met or the current device is functioning appropriately, and non-implantable VNS devices are not covered for any condition.

"Implantation of a vagus nerve stimulation device is consideredmedically necessaryin an individual with medically and surgically refractory seizures as evidenced by:Failure of more than one trial of..."