Prior Authorization Required

Prior Authorization Required: Requests for implantation of neurostimulator devices, leads, and implanted pulse generators (including CPT and HCPCS codes listed in this policy) typically require prior authorization consistent with Health Plan rules. Providers should obtain authorization before scheduling implant or device-related procedures to avoid claim denials or delays.

• Affected codes include (but are not limited to): CPT 63650, 63655, 63685, 64555, 64575, 64585, 64590, 64595, 64596-64598, 64999 and HCPCS L8678-L8688.
• Prior authorization is also recommended for device programming and electronic analysis services (e.g., CPT 95970) when performed in conjunction with implanted neurostimulator systems.

General Documentation Expectations

Documentation Expectations: Providers must submit clinical documentation that supports medical necessity for the requested service. Documentation should reference relevant CPT descriptions and include detailed clinical information such as diagnosis, prior treatments, symptom duration and severity, response to conservative therapy, rationale for device selection, and any contraindications to alternative treatments. Include operative reports, device and model details (brand/model when applicable), imaging, specialist consultations, psychological evaluation when required by criteria, and objective measures of function or pain when available. Coverage determinations remain subject to the Health Plan's benefit terms, limitations, and coding edits.

• Supply copies of trial stimulation records, stimulation parameters, and outcomes if applicable.
• If requesting revision, replacement, or removal, include prior device implantation details and reason for revision/removal (e.g., infection, device failure, loss of efficacy).

Conservative Therapy Requirement

Conservative Therapy Requirement: Prior conservative therapy must be documented before implanting permanent neurostimulation devices unless the patient meets specific exception criteria (e.g., not a candidate for surgery, acute indications where implant is indicated per policy). Examples of conservative therapies include physical therapy, targeted exercise programs, medication management (including trials of appropriate analgesics or neuropathic agents), interventional procedures (e.g., epidural injections, nerve blocks), and structured multidisciplinary pain management programs. Document the type, duration, frequency, and clinical response to each conservative therapy attempted.

• Include dates and objective evidence of inadequate response to conservative measures.
• When trial stimulation was performed, document trial duration and response to support progression to permanent implantation.

CPT Codes That Do Not Support Coverage Criteria

Not Supported CPT Code(s): Requests involving CPT 0720T (percutaneous electrical nerve field stimulation, cranial nerves, without implantation) are not supported by the coverage criteria and should not be submitted as covered services under this policy.

• CPT 0720T is listed as not supporting the coverage criteria.