Regence Medicare Advantage Policy Manual TOPIC: Vagus Nerve Stimulation Section: Medicare Manual – Surgery Approval Date: May 2014 Policy No: M-SUR74 Published Date: 01/01/2015 IMPORTANT REMINDER: The health plan’s Medicare Advantage Medical Policies are developed to provide guidance for members and providers regarding coverage in accordance with the member Evidence of Coverage (EOC) booklet. Benefit determinations are based in all cases on any applicable EOC language and any applicable CMS policy. To the extent there may be any conflict, applicable EOC language or applicable CMS policy take precedence over the health plan’s Medicare Advantage Medical Policy. MEDICARE MEDICAL POLICY CRITERIA CMS Coverage Manuals None National Coverage Determinations (NCD) For medically refractory partial onset seizures, all other types of seizure disorders, and depression: Vagus Nerve Stimulation (VNS) (160.18) Noridian Healthcare Solutions (Noridian) Local Coverage Determinations (LCD) and Articles (LCA) For obesity (CPT Category III codes 0312T, 0313T, 0316T, and 0317T): Non-Covered Services (L24473) • Idaho • Oregon • Utah • Washington **Scroll to the “All Versions” section at the bottom of the LCD to access prior versions. Medical Policy Manual For all other indications: Vagus Nerve Stimulation, Surgery, Policy No. 74 1 – M-SUR74 NOTE: Vagus nerve stimulation is considered to be investigational for some indications not already addressed above. For Medicare Advantage, experimental (i.e., investigational) services are considered not medically necessary as they have not yet been proven to be safe and effective based on peer reviewed scientific literature [see the Medical Policy Development Process and LCD for Non-Covered Services (L24473)*]. *Noridian LCD for Non-Covered Services (L24473) can be found on the Medicare Coverage Database website. Enter the LCD number “L24473” into the Document ID search field. The database search engine will automatically request a date of service to ensure the correct version is selected. Select the appropriate result based on the following contractor name and number assignments: Idaho = Noridian Healthcare Solutions, LLC (02102) Oregon = Noridian Healthcare Solutions, LLC (02302) Utah = Noridian Healthcare Solutions, LLC (03502) Washington = Noridian Healthcare Solutions, LLC (02402) REFERENCES None CROSS REFERENCES Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy, Surgery, Policy No. M-16 CODES NUMBER DESCRIPTION CPT 61885 61886 61888 64553 64568 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array With connection to two or more electrode arrays Revision or removal of cranial neurostimulator pulse generator or receiver Percutaneous implantation of neurostimulator electrode array; cranial nerve Incision for implantation of cranial nerve (e.g., vagus nerve) 2 – M-SUR74 CODES NUMBER DESCRIPTION 64569 64570 95970 95971 95974 ; complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour 95975 ; complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (list separately in addition to code for primary procedure) Vagus nerve blocking therapy (morbid obesity); laparoscopic implantation of neurostimulator electrode array, anterior and posterior vagal trunks adjacent to esophagogastric junction (EGJ), with implantation of pulse generator, includes programming Vagus nerve blocking therapy (morbid obesity); laparoscopic revision or replacement of vagal trunk neurostimulator electrode array, including connection to existing pulse generator Vagus nerve blocking therapy (morbid obesity); laparoscopic removal of vagal trunk neurostimulator electrode array and pulse generator Vagus nerve blocking therapy (morbid obesity); removal of pulse generator Vagus nerve blocking therapy (morbid obesity); replacement of pulse generator Vagus nerve blocking therapy (morbid obesity); neurostimulator pulse generator electronic analysis, includes reprogramming when performed Implantable neurostimulator, pulse generator, any type 0312T 0313T 0314T 0315T 0316T 0317T HCPCS neurostimulator electrode array and pulse generator Revision or replacement of cranial nerve (e.g., vagus nerve) neurostimulator electrode array, including connection to existing pulse generator Removal of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord or peripheral (ie, cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming ; simple spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming L8679 L8680 Implantable neurostimulator electrode, each (Code non-covered by Medicare – see L8679) 3 – M-SUR74 CODES NUMBER DESCRIPTION L8681 L8682 L8683 L8685 L8686 L8687 L8688 L8689 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only Implantable neurostimulator radiofrequency receiver Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (Code non-covered by Medicare – see L8679) Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (Code non-covered by Medicare – see L8679) Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (Code non-covered by Medicare – see L8679) Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (Code non-covered by Medicare – see L8679) External recharging system for battery (internal) for use with implantable neurostimulator 4 – M-SUR74
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