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    v1.0.28
    OpenPayerPolicy UpdatesNeurology/NeurosurgeryAmbetter Nevada VNS Coverage Update | OpenPayer
    Ask Trek AI about this page
    ModifiedAmbetter NevadaPolicy WA.CP.MP.12

    Vagal Nerve Stimulation

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    This policy governs coverage of implantable vagus nerve stimulation, primarily for epilepsy, and identifies other VNS indications and device types as unproven or unsupported by current evidence.

    Policy Summary
    PayerAmbetter Nevada
    PolicyVagal Nerve Stimulation
    Policy CodePolicy WA.CP.MP.12
    Change TypeModified
    Effective DateOctober 1, 2026
    Last ReviewAug 1, 2026
    Next Review DateNot specified
    Key ActionConfirm the member is at least 4 years old, has failed adequate trials of at least 3 appropriate antiseizure medications, and has no recommended or successful surgical alternative before requesting implantable VNS for epilepsy.
    SourceLink
    POLICY UPDATE CHANGES

    The policy was updated to specify that the covered epilepsy indication is implantable vagus nerve stimulation.

    The investigational headache language was updated to specifically include cluster headaches and migraines.

    HCPCS code K1020 was removed from the policy coding information.

    The policy was revised to specify implantable vagus nerve stimulation in Criterion I.

    Investigational headache language was updated to include cluster headaches and migraines.

    CPT and HCPCS codes were updated to better align with billing guidelines.

    HCPCS code K1020 was removed from the policy's code tables.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    4+Minimum age
    3+Required antiseizure medication trials
    26Other conditions not proven or unsupported
    4CPT codes listed
    10HCPCS codes supporting coverage
    1HCPCS codes removed

    Vagus Nerve Stimulation Coverage Criteria

    Implantable VNS for epilepsy

    Covered as medically necessary when all of the following are met:

    Initial implantable VNS for epilepsy

    • Minimum age and treatment criteria

      • Minimum age: Member/enrollee is 4 years of age or over.>= 4 years
      • Refractory seizure disorder: Seizure disorder is refractory to medical treatment, defined as adequate trials of at least 3 appropriate but different anti-epileptic medications.At least 3 adequate trials

      • Surgical treatment status

        • Surgical treatment is not recommended.
        • Surgical treatment has failed.

    Other conditions not proven for VNS

    Safety and efficacy have not been proven for the following conditions:

    Non-covered or unproven conditions

    • Conditions: Refractory (treatment-resistant) major depression or bipolar disorder; headaches, including cluster headaches and migraines; cognitive impairment associated with Alzheimer's disease; addiction; anxiety disorders; autism; eating disorders; cancer; Crohn's disease; essential tremor; fibromyalgia; heart failure; impaired glucose tolerance or pre-diabetes; inflammation; overweight or obesity; obsessive-compulsive disorder; panic disorder; post-traumatic stress disorder; Prader-Willi syndrome; Sjogren's syndrome; rheumatoid arthritis; schizophrenia; sleep disorders; stroke; tinnitus; Tourette's syndrome; and traumatic brain injury.

    Unsupported device types

    Current research does not support these VNS types over other currently available alternatives because of a lack of large, high-quality studies supporting their use:

    Unsupported VNS modalities

    • Aspire SR Model 106 (Cyberonics) for VNS.
    • Transcutaneous VNS or active auricular transcutaneous electrical nerve stimulation.

    VNS is not supported when used for conditions other than the qualifying epilepsy indication because safety and efficacy have not been proven. This includes refractory (treatment-resistant) major depression or bipolar disorder; headaches, including cluster headaches and migraines; cognitive impairment associated with Alzheimer’s disease; addiction; anxiety disorders; autism; eating disorders; cancer; Crohn’s disease; essential tremor; fibromyalgia; heart failure; impaired glucose tolerance or prediabetes; inflammation; overweight or obesity; obsessive-compulsive disorder; panic disorder; post-traumatic stress disorder; Prader-Willi syndrome; Sjogren’s syndrome; rheumatoid arthritis; schizophrenia; sleep disorders; stroke; tinnitus; Tourette’s syndrome; and traumatic brain injury.

    Current research does not support Aspire SR Model 106 (Cyberonics) VNS, transcutaneous VNS, or active auricular transcutaneous electrical nerve stimulation over other available alternatives. The policy cites a lack of large, high-quality studies supporting these types of VNS therapy.

    Coding and Threshold Requirements

    CPT CodesCPT
    61885Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array.
    61886Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays.
    64553Percutaneous implantation of neurostimulator electrode array; cranial nerve.
    64568Open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator.
    HCPCS Codes that Support Coverage CriteriaHCPCSCovered
    C1767Generator, neurostimulator (implantable), nonrechargeable.
    C1778Lead, neurostimulator (implantable).
    L8680Implantable neurostimulator electrode, each.
    L8682Implantable neurostimulator radiofrequency receiver.
    L8683Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver.
    L8685Implantable neurostimulator pulse generator, single array, rechargeable, includes extension.
    L8686Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension.
    L8687Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension.
    L8688Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension.
    Historical ICD-10 and HCPCS Coding Changesmixed
    G40.001Removed from the policy coding list per revision log.
    G40.009Removed from the policy coding list per revision log.
    G40.201Removed from the policy coding list per revision log.
    G40.209Removed from the policy coding list per revision log.
    G40.309Removed from the policy coding list per revision log.
    G40.A09Removed from the policy coding list per revision log.
    G40.409Removed from the policy coding list per revision log.
    G40.509Removed from the policy coding list per revision log.
    G40.802Removed from the policy coding list per revision log.
    G40.813Added to the policy coding list per revision log.
    1–10 of 15
    1/2
    Removed HCPCS CodeHCPCS
    K1020HCPCS code removed from the policy's code tables
    Minimum Age
    Minimum age4 years of age or over
    Applies toMedically necessary implantable vagal nerve stimulation (VNS) for epilepsy
    Required with age criterionThe seizure disorder must also be refractory to medical treatment and surgical treatment must not be recommended or must have failed
    Prior Antiseizure Medication Trials
    Required number of trialsAt least 3 adequate trials
    Medication typeAppropriate but different anti-epileptic medications

    Provider Review and Denial Risks

    Denial Risk

    Epilepsy Criteria Not Met

    Do not approve implantable VNS for epilepsy unless all medical-necessity criteria are documented. Deny when the member is younger than 4, the seizure disorder is not refractory after adequate trials of at least 3 appropriate but different anti-epileptic medications, or surgical treatment is recommended and has not failed.

    • Member/enrollee must be age 4 or older.
    • Seizure disorder must be refractory to medical treatment, defined as adequate trials of at least 3 appropriate but different anti-epileptic medications.
    • Surgical treatment must not be recommended or must have failed.
    Denial Risk

    Unproven Non-Epilepsy Indication

    VNS for non-qualifying conditions is unproven and unsupported. Do not approve VNS for indications other than qualifying epilepsy, including the following conditions listed in the policy.

    • Refractory or treatment-resistant major depression, unipolar major depression, or bipolar disorder

    Vagus Nerve Stimulation Background

    Vagus nerve stimulation (VNS) uses an implanted neurocybernetic prosthesis to provide chronic, intermittent electrical stimulation to the cervical portion of the left vagus nerve. The device is typically implanted beneath the skin of the left chest, with a second incision at the base of the neck, generally as an outpatient procedure under general anesthesia. The policy describes evidence supporting possible improvement in medically refractory focal-onset seizures when the patient is not suitable for surgery or when surgical treatment has failed; evidence for other indications remains insufficient.

    Key Definitions

    Refractory Seizure Disorder
    DefinitionA seizure disorder that is refractory to medical treatment
    Trial standardAdequate trials of at least 3 appropriate but different anti-epileptic medications
    Coverage contextThis standard is part of the criteria for medically necessary implantable VNS for epilepsy
    Transcutaneous VNS
    DefinitionVagus nerve stimulation delivered noninvasively through the skin
    Ear stimulationStimulation applied to the ear, including the auricular branch of the vagus nerve
    Cervical stimulation
    Policy Summary
    PayerAmbetter Nevada
    PolicyVagal Nerve Stimulation
    Policy CodePolicy WA.CP.MP.12
    Change TypeModified
    Effective DateOctober 1, 2026
    Last ReviewAug 1, 2026
    Next Review DateNot specified
    Key ActionConfirm the member is at least 4 years old, has failed adequate trials of at least 3 appropriate antiseizure medications, and has no recommended or successful surgical alternative before requesting implantable VNS for epilepsy.
    SourceLink
    On This Page
    Vagus Nerve Stimulation Coverage CriteriaCoding and Threshold RequirementsProvider Review and Denial RisksVagus Nerve Stimulation BackgroundKey Definitions
    Clinical contextThe seizure disorder must be refractory to medical treatment
  1. Headaches, including cluster headaches and migraines
  2. Cognitive impairment or cognitive deficits associated with Alzheimer's disease
  3. Addiction
  4. Anxiety disorders
  5. Autism
  6. Eating disorders
  7. Cancer
  8. Crohn's disease
  9. Essential tremor
  10. Fibromyalgia
  11. Heart failure
  12. Impaired glucose tolerance or pre-diabetes
  13. Inflammation
  14. Overweight, obesity, or resistant obesity
  15. Obsessive-compulsive disorder
  16. Panic disorder
  17. Post-traumatic stress disorder (PTSD)
  18. Prader-Willi syndrome
  19. Sjogren's syndrome
  20. Rheumatoid arthritis
  21. Schizophrenia
  22. Sleep disorders
  23. Stroke
  24. Tinnitus
  25. Tourette's syndrome
  26. Traumatic brain injury
    27. Denial Risk

    Unsupported VNS Device Type

    Do not approve unsupported VNS device types or delivery methods. Current research does not support these alternatives over available options because large, high-quality studies establishing safety and efficacy are lacking.

    • Aspire SR Model 106 (Cyberonics) for VNS, including its AutoStim-enabled implantable device
    • Transcutaneous or non-implantable VNS (tVNS), including cervical noninvasive VNS systems such as gammaCore and Phoenix
    • Active auricular transcutaneous electrical nerve stimulation, including auricular tVNS systems that stimulate the ear
    Noninvasive stimulation applied superficially near the cervical vagus nerve using a specially designed device