Prior authorization required for implantable VNS procedures and devices

Prior authorization is required for implantation, revision, removal, and associated implantable device supplies; requests must reference the CPT and HCPCS codes for the planned procedure and device.

• Examples of relevant CPT/HCPCS codes include CPT 64553, 64568-64570, 61885, 61886, 61888 and HCPCS device codes C1767, C1778, L8685-L8689.

Prior authorization expected for implantable VNS procedures

Authorization is expected when billing the listed implantable VNS procedure and device codes; follow plan-specific prior authorization processes when submitting claims for these CPT and HCPCS codes.

• Covered procedure CPT codes include 64553, 64568, 64569, 64570.
• Supporting HCPCS device codes include C1767, C1778 and L8680–L8689.

Prior medication trials required

Member must have failed an adequate trial of at least two anti‑seizure medications with adherent therapy for at least one year before VNS is considered medically necessary.

• Policy text: “Failure of at least one year of adherent therapy of at least two anti‑seizure drugs.”

Step therapy: none specified in this document excerpt

No explicit step therapy program requirements are stated in this portion of the policy.

Required clinical documentation for authorization

Include documentation showing the diagnosis (focal or generalized onset seizures), history of intractable epilepsy with continued seizures impacting activities of daily living, failure of at least two anti‑seizure drugs for ≥1 year, unsuitability/failed epilepsy surgery, and that the request is for an FDA‑approved device.

• Document seizure frequency/impact on activities of daily living.
• Specify prior anti‑seizure medications, durations, and adherence.
• Indicate prior epilepsy surgery candidacy, refusal, or failure, and identify the FDA‑approved device requested.

Document medical necessity and follow program-specific guidance

Document medical necessity in accordance with this clinical policy and applicable coverage documents; for Medicaid and Medicare members, follow state Medicaid manual provisions and any applicable NCDs/LCDs.

• State Medicaid coverage provisions take precedence where they conflict with this policy.
• Review Medicare NCDs, LCDs, and Coverage Articles prior to applying these criteria.

Non‑covered / investigational indications will be denied

Requests for VNS for indications other than medically refractory seizures (for example treatment‑resistant major depression, headaches, Alzheimer’s cognitive impairment, PTSD, obesity, etc.) are considered not proven and may be denied.

• Policy lists multiple non‑supported indications including refractory depression, headaches, Alzheimer’s cognitive impairment, addiction, anxiety disorders, autism, eating disorders, cancer, Crohn’s disease, essential tremor, fibromyalgia, heart failure, impaired glucose tolerance/pre‑diabetes, inflammation, overweight/obesity, OCD, panic disorder, PTSD, and others.

Noninvasive VNS (HCPCS K1020) not supported

Noninvasive VNS devices represented by HCPCS code K1020 are listed in the table of HCPCS codes that do not support coverage criteria and are not supported by this policy excerpt.

• HCPCS K1020 = Noninvasive vagus nerve stimulator (listed as not supporting coverage criteria).