Medical technologies and investigational transplant-related devices/services
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Lists investigational, investigational-with-exceptions, and coverage notes for medical devices and technologies relevant to transplant program case management and other services; applies to EmblemHealth members and providers requesting review or pre-certification.
No material clinical or coverage changes in this revision.
Coverage Determinations and Policy Statements
Scalp cooling coverage
Scalp cooling for chemotherapy-related hair loss
CPT 0662T, 0663T cited
AbioCor® coverage handling
AbioCor® Implantable Replacement Heart (HDE)
CPT 33927, 33928, 33929, L8698
Reclaim™ DBS coverage handling
Reclaim™ DBS Therapy
CPT codes listed in database rows (e.g., 21499, 61863–61888, 95961–95962)
Vagus Nerve Stimulation
Coverage stance is indicated per technology:
CPT 0312T–0317T, 61885, 61886, 61888; see MCG #A‑0424 and Medicare NCD
Venoplasty for Multiple Sclerosis
CPT 36901–36906 listed
Cooling caps and other scalp cooling products are considered incidental to chemotherapy administration and are not separately reimbursed. Items purchased by the member (for example, scalp cooling caps) may be treated as excluded supplies under plans that exclude supplies. Relevant CPT codes: 0662T, 0663T.
Requests for vagus nerve stimulation (VNS) for indications listed as investigational are considered investigational and may be denied. VNS is considered investigational for most indications except for epilepsy (see MCG #A-0424) and treatment‑resistant depression (TRD) for Medicare members under the NCD CED pathway. Examples of investigational indications include addictions, Alzheimer disease, anxiety disorders, atrial fibrillation, autism spectrum disorders, chronic pain syndromes, migraine/headaches, sleep disorders, tinnitus, traumatic brain injury, and many others as listed in the database. Relevant CPT codes include 0312T–0317T, 61885, 61886, 61888.
Laser interstitial thermal therapy (LITT) is listed as not medically necessary for all indications other than epilepsy and intracranial lesions as depicted elsewhere in the database. Applicable unlisted and site‑specific CPT codes are provided in the database rows (for example, CPT series including 19499, 20999, 27599, 32999, 47399, 53899, 55899 are cited for LITT entries).
Venoplasty for relapsing‑remitting multiple sclerosis is listed as investigational (not considered an established therapy) and may be denied. Relevant CPT codes listed for venoplasty include 36901–36906.
Procedure and Billing Codes
| 0662T | Scalp cooling device code |
| 0663T | Scalp cooling device code |
| 21499 | Unlisted procedure code referenced for DBS therapy entries |
| 61863 | Deep brain stimulation-related code |
| 61864 | Deep brain stimulation-related code |
| 61867 | Deep brain stimulation-related code |
| 61885 | Deep brain stimulation-related code |
| 61886 | Deep brain stimulation-related code |
| 61880 | Deep brain stimulation-related code |
| 61888 | Deep brain stimulation-related code |
| 95961 | Neurodiagnostic code referenced |
| 95962 | Neurodiagnostic code referenced |
Actions Required by Providers and Prior Authorization
Pre-authorization Required for AbioCor® Device
Pre-certification is required for requests related to the AbioCor® Implantable Replacement Heart. These requests are reviewed on a case-by-case basis for all lines of business except Medicare, where coverage follows the applicable National Coverage Determination (NCD) and CMS rules for clinical studies meeting NCD criteria.
- Pre-certification required for commercial and Medicaid LOBs; Medicare follows NCD/clinical study payment rules.
Scalp Cooling — Not Separately Reimbursed
Cooling caps and other scalp cooling products are considered incidental to chemotherapy administration and are not separately reimbursed. Items purchased by the member are generally considered excluded supplies when the plan excludes supplies.
- Cooling caps/products incidental to chemotherapy — not separately reimbursed.
- Member-purchased cooling products treated as excluded supplies when plan excludes supplies.
Prior Authorization and Coverage Limits for Vagus Nerve Stimulation (VNS)
Vagus nerve stimulation (VNS) requires prior authorization. VNS is considered medically appropriate only for epilepsy per MCG guidance and for treatment‑resistant depression (TRD) under Medicare only through the NCD Coverage with Evidence Development (CED) pathway. Requests for VNS for other indications are considered investigational and may be denied.
- Prior authorization required.
- Covered indications: Epilepsy (per MCG #A-0424) and Medicare TRD via NCD/CED only.
- VNS for all other indications is investigational — may be denied.
Documentation Required for VNS Requests
When VNS is requested, submit documentation demonstrating the member meets the applicable indication (epilepsy criteria per MCG or Medicare TRD CED enrollment/documentation). Without adequate documentation, prior authorization may be denied.
- Provide clinical documentation supporting epilepsy diagnosis and MCG criteria OR Medicare TRD CED enrollment and study documentation.
- Include relevant prior treatments, response history, and specialty evaluations as applicable.
Venoplasty for Relapsing‑Remitting Multiple Sclerosis — Investigational
Venoplasty for relapsing‑remitting multiple sclerosis (RRMS) is considered investigational and is not covered. Prior authorization may be required for venoplasty procedures generally, but venoplasty for RRMS will be denied as investigational.
- Venoplasty for relapsing‑remitting MS — investigational; not covered.
- Prior authorization may still be required for vascular procedures; submit documentation but expect investigational denial for RRMS indication.
Transplant Case Management and Pre-certification
EmblemHealth’s transplant program manages members preparing for or recovering from solid organ or bone marrow transplants. All transplant services are reviewed with the transplant program medical director as part of the pre-certification and case management process. To request transplant case management services, members and providers may call 1‑800‑447‑0768.
- All requested transplant services are reviewed for medical necessity with the transplant program medical director.
- Call 1-800-447-0768 to request transplant case management services.
Program Background and Scope
EmblemHealth operates a transplant program that manages members preparing for or having solid organ or bone marrow transplants. All transplant services are reviewed with the medical director assigned to the transplant case management program and are assessed for medical necessity using evidence‑based criteria; providers or members may contact the transplant program for case management and pre‑certification coordination.
Key Definitions and Abbreviations
Transplant Candidate Eligibility and Management
Transplant case management criteria
Transplant program management and review
Call 1‑800‑447‑0768
Clinical Evaluation and Documentation Requirements
EVALUATION REQUIREMENTS
Requested transplant services are reviewed for medical necessity and assessed using evidence‑based criteria to support care coordination and outcomes; include sufficient clinical documentation to demonstrate necessity.
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