CurrentConnectiCarePolicy MG.MM.SU.69

Cortical Stimulation for Epilepsy (NeuroPace®)

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ConnectiCare medical-necessity review and prior authorization for cortical responsive neurostimulation for epilepsy, including implantation, replacement, revision, removal, and related device services.

Policy Summary

PayerConnectiCare

PolicyCortical Stimulation for Epilepsy (NeuroPace®)

Policy CodePolicy MG.MM.SU.69

Change TypeMaterial clinical and coverage update

Effective DateSeptember 11, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence demonstrating that the member meets the policy’s medical-necessity criteria before treatment or the applicable surgical/device service.

SourceLink

POLICY UPDATE CHANGES

The policy clarified clinical criteria for focal-onset seizures, seizure localization, medication failure, and disabling functional impact.

The policy added a requirement for specialist evaluation and clearance before implantation when members have signs or symptoms of obstructive sleep apnea.

The policy removed the prerequisite that the member must not be a candidate for focal resective epilepsy surgery.

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CurrentConnectiCarePolicy MG.MM.SU.69

Cortical Stimulation for Epilepsy (NeuroPace®)

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Policy Summary

PayerConnectiCare

PolicyCortical Stimulation for Epilepsy (NeuroPace®)

Policy CodePolicy MG.MM.SU.69

Change TypeMaterial clinical and coverage update

Effective DateSeptember 11, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence demonstrating that the member meets the policy’s medical-necessity criteria before treatment or the applicable surgical/device service.

SourceLink

POLICY UPDATE CHANGES

The policy clarified clinical criteria for focal-onset seizures, seizure localization, medication failure, and disabling functional impact.

The policy added a requirement for specialist evaluation and clearance before implantation when members have signs or symptoms of obstructive sleep apnea.

The policy removed the prerequisite that the member must not be a candidate for focal resective epilepsy surgery.

≥18 yearsMinimum member age

≥2Required medication failures

2Documented seizure-origin areas

All other indicationsExperimental indications

<50,000Platelet contraindication

Medical Necessity, Limitations, and Exclusions

Initial Cortical Stimulation Medical Necessity

Cortical stimulation is considered medically necessary when ALL of the following criteria are met:

ALL of the following

Member is 18 years of age or older.
Member has partial (focal-onset) seizures.
Seizures originate from two specific, localized areas of the brain.
Seizures continue despite treatment with at least two appropriately chosen and tolerated antiepileptic medications.≥ 2 medications
Seizures are disabling and significantly impact the member’s ability to function or carry out daily activities.
Member is not a VNS candidate because of ANY of the following
- A condition related to the contralateral recurrent laryngeal nerve.
- Swallowing problems that may be exacerbated by VNS implantation.
- Obstructive sleep apnea (OSA).
  Members with signs or symptoms of OSA should be evaluated and cleared by an appropriate specialist before implantation.
- Previous left-sided neck surgery.
- Asthma or chronic obstructive pulmonary disease (COPD) that may be exacerbated by VNS implantation.

Limitations and Exclusions

Coverage is excluded for experimental or investigational indications and when the RNS System is contraindicated.

ANY of the following limitations or exclusions applies

Responsive cortical stimulation is used for primary generalized seizures or for any other indication not meeting the covered focal-seizure criteria.
Patient is at high risk for surgical complications, including active systemic infection, a coagulation disorder such as use of antithrombotic therapy, or a platelet count below 50,000.
Patient has a medical device implanted that delivers electrical energy to the brain.
Patient is unable, or lacks the necessary assistance, to properly operate the NeuroPace remote monitor or magnet.

Responsive cortical stimulation is considered experimental and investigational for primary generalized seizures and for all other indications.

The RNS System is contraindicated for patients at high risk for surgical complications, including those with active systemic infection, coagulation disorders such as use of antithrombotic therapies, or a platelet count below 50,000; patients who have medical devices implanted that deliver electrical energy to the brain; and patients who are unable, or do not have the necessary assistance, to properly operate the NeuroPace remote monitor or magnet.

Procedure and Diagnosis Coding

Procedure CodesCPT

61850	Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical.
61860	Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical.
61863	Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array.
61864	Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; each additional array (List separately in addition to primary procedure).
61880	Revision or removal of intracranial neurostimulator electrodes.
61885	Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array.
61886	Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays.
61888	Revision or removal of cranial neurostimulator pulse generator or receiver.

Procedure CodesHCPCS

L8688

Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension.

Diagnosis CodesICD-10

G40.011	Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus.
G40.019	Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus.
G40.111	Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus.
G40.119	Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus.
G40.211	Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus.
G40.219	Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus.

Minimum age

Minimum age≥ 18 years

Applies toMembers with epilepsy being evaluated for medically necessary cortical stimulation

Medical-necessity impactRequests may fail the clinical criteria when the member is younger than 18

Failed antiepileptic medications

Required number≥ 2 antiepileptic medications

Treatment standardMedications must be appropriately chosen and tolerated

Authorization and Documentation Requirements

Prior Authorization

Submit Clinical Evidence Before Treatment

Before treatment or surgery, the treating physician or primary care provider must submit clinical evidence showing that the member meets the policy criteria. Without this documentation, ConnectiCare cannot properly review the prior authorization request.

Submit the clinical evidence with the prior authorization request.
Evidence must support the requested cortical stimulation treatment or surgical procedure.

Documentation Required

Document Failure of Two Antiepileptic Medications

Document that disabling focal-onset seizures continue despite treatment with at least two appropriately chosen and tolerated antiepileptic medications.

Include the medications tried, including their appropriateness and tolerability.
Describe the ongoing seizures and treatment response.

Cortical Stimulation Overview

Cortical stimulation involves implanting electrodes on the surface of the brain near areas associated with seizure activity. The NeuroPace RNS System is a responsive neurostimulation system consisting of an implanted neurostimulator with one or two depth or cortical strip leads, together with external programming, monitoring, and magnet components. The policy addresses adults with medically refractory focal-onset epilepsy involving two localized seizure areas when seizures continue despite medication treatment and have a disabling impact on function or daily activities.

Key Clinical Terms

Cortical stimulation

ProcedureImplantation of electrodes onto the surface of the brain

LocationNear areas associated with seizure activity

Device contextThe electrodes may be part of a cortical strip lead placed on the brain surface near the seizure focus

Focal onset seizures

DefinitionSeizures that begin in one area or group of cells on one side of the brain

Current terminologyFocal onset seizures

Prior terminologyPreviously called partial seizures

Policy Summary

PayerConnectiCare

PolicyCortical Stimulation for Epilepsy (NeuroPace®)

Policy CodePolicy MG.MM.SU.69

Change TypeMaterial clinical and coverage update

Effective DateSeptember 11, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence demonstrating that the member meets the policy’s medical-necessity criteria before treatment or the applicable surgical/device service.

SourceLink

On This Page

Seizures must continue despite treatment with these medications

Platelet count contraindication

Platelet thresholdPlatelet count below 50,000

Policy statusListed as a contraindication to the RNS System

Clinical contextIncluded among conditions creating a high risk for surgical complications

Documentation Required

Clinical Evidence for Review

Provide provider-submitted clinical evidence supporting medical necessity for treatment and any related surgical prerequisites. The evidence should allow ConnectiCare to evaluate the request under the clinical review criteria.

Include relevant clinical records, diagnostic findings, and treatment history.
Submit documentation supporting the requested procedure before treatment.

Unsupported block type: documentation

Prior Authorization

OSA Evaluation and Clearance

Members with signs or symptoms of obstructive sleep apnea must be evaluated and cleared by an appropriate specialist before implantation.

Submit the specialist evaluation and clearance with the authorization documentation.
Do not proceed with implantation without the required clearance.

Denial Risk

Experimental or Investigational Indications

Responsive cortical stimulation is experimental and investigational for primary generalized seizures and for all other indications.

Primary generalized seizures are not covered under this indication.
Other indications outside the covered focal-onset criteria are experimental and investigational.

Denial Risk

Review RNS Contraindications

Confirm that no RNS System contraindication is present before requesting or performing implantation.

High risk for surgical complications, including active systemic infection.
Coagulation disorders, including use of antithrombotic therapies, or platelet count below 50,000.
An implanted medical device that delivers electrical energy to the brain.
Inability to properly operate the NeuroPace remote monitor or magnet, or lack of necessary assistance to do so.

Denial Risk

Failure to Meet Clinical Criteria

Requests may be denied when the clinical evidence or documentation does not establish every required criterion, when the indication is experimental or investigational, or when an RNS contraindication is present.

Incomplete or missing provider-submitted evidence may prevent proper prior authorization review.
Failure to document the required seizure characteristics, treatment failures, functional impact, VNS non-candidacy, or OSA clearance when applicable creates denial risk.
Coverage remains subject to the member's benefit plan and applicable coverage limitations.

Focal onset aware seizures

DefinitionA focal seizure during which the person is awake and aware

Current terminologyFocal onset aware seizure

Prior terminologyPreviously termed simple partial seizure

Focal onset impaired awareness seizures

DefinitionA focal seizure during which the person's awareness is confused or affected

Current terminologyFocal onset impaired awareness seizure

Prior terminologyPreviously termed complex partial seizure

Medically refractory seizures

DefinitionSeizures that occur despite treatment with therapeutic levels of antiepileptic drugs

Alternative circumstanceSeizures that cannot be treated with therapeutic levels of antiepileptic drugs because of intolerable adverse side effects

Treatment contextThe definition is based on persistence despite therapeutic antiepileptic treatment or inability to tolerate such treatment