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    v1.0.28
    OpenPayerPolicy UpdatesNeurology/Neurosurgeryeocco VNS Coverage Prior Auth Policy Update | Open…
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    CurrenteoccoPolicy N/A

    Vagus Nerve Stimulation (VNS)

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    Clinical coverage and medical necessity criteria for implantable vagus nerve stimulation (VNS) systems as adjunctive therapy for medically refractory partial/focal onset seizures, and coverage stance for other indications. Applies to Eocco plan administration and providers requesting authorization or replacement of VNS devices.

    Policy Summary
    Payereocco
    PolicyVagus Nerve Stimulation (VNS) — coverage criteria for implantable VNS systems
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateJun 1, 2026
    Last ReviewMay 27, 2026
    Next Review DateMay 27, 2026
    Key ActionObtain prior authorization and submit neurologist records documenting diagnosis, prior medical/surgical treatments, and eligibility (age ≥4 years).
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    >=4Minimum age

    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.

    Refractory seizures
    Primary indication
    Not coveredDepression
    ExtensiveICD-10 list

    Coverage and Medical Necessity Criteria

    Initial Therapy

    Covered when ALL of the following are met

    Primary coverage criteria for VNS: A. The member is 4 years of age or older (FDA approved for 4 years and older); B. The member has not had a bilateral or left cervical vagotomy; C. The member has medically refractory partial-onset seizures and one or more of: (i) seizures despite therapeutic levels of anti-epileptic medications; OR (ii) seizures cannot be treated with therapeutic levels of anti-epileptic drugs because of intolerable side effects; D. Unsuccessful surgical intervention (lesionectomy or medial temporal lobectomy) with one or more of: (i) seizures refractory to surgical intervention; OR (ii) patient was not a surgical candidate; OR (iii) patient refused surgical intervention.age >=4 years

    VNS is considered medically necessary DME when all conditions are met.

    Replacement/Revision

    Replacement/Revisions

    Replacement or revision coverage: Replacement or revision of a vagus nerve therapy system or handheld magnet is considered medically necessary when the original system or magnet met the policy's medical necessity criteria and the device is no longer under warranty and cannot be repaired.

    Supports coverage for non-warranty replacements when prior criteria were met.

    Device Analysis/Programming

    Device analysis

    Device interrogation/analysis: Electronic analysis (interrogation/programming) of an implanted neurostimulator pulse generator system for VNS is considered medically necessary when the policy's medical necessity criteria are met.

    Covers device analysis and programming when clinically indicated.

    Vagus nerve stimulation (VNS) is considered experimental and investigational for all indications other than medically refractory partial‑onset (focal) epilepsy. Examples of indications for which VNS is investigational include, but are not limited to: addictions, Alzheimer’s disease, anxiety disorders, autism, cognitive impairment associated with Alzheimer’s disease, depression, headaches, obesity, obsessive‑compulsive disorder, Tourette’s syndrome, sleep disorders, heart failure, essential tremors, Crohn’s disease, pain syndromes, bulimia, cerebral palsy, coma, cancer, and generalized epilepsy syndromes. The effectiveness of VNS for these conditions has not been established.

    Vagus nerve stimulation (VNS) is considered experimental and investigational for treatment‑resistant depression due to insufficient evidence from well‑designed controlled clinical trials. The policy notes that only one randomized controlled trial has been identified and that it did not demonstrate statistically significant improvement on most measures of depression, so available evidence is inadequate to conclude that VNS improves health outcomes or is superior to alternative therapies for depression.

    Codes, Age Limits, and Billing

    Applicable CPT/HCPCS Codesmixed
    61885Insertion or replacement of cranial neurostimulator pulse generator or receiver; with connection to a single electrode array.
    61886Insertion or replacement of cranial neurostimulator pulse generator; with connection to two or more electrode array.
    64553Percutaneous implantation of neurostimulator electrodes; cranial nerve.
    64568Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator; programming when performed.
    64569Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator.
    64570Removal of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator; including connection to existing pulse generator.
    L8680Implantable neurostimulator electrode, each.
    L8681Patient programmer (external) for use with implantable programmable neurostimulator.
    L8683Radiofrequency transmitter (external) for use with implantable neurostimulator.
    L8685Implantable neurostimulator pulse generator, single array, rechargeable, includes extension.
    1–10 of 14
    1/2
    Covered Diagnosis Codes (ICD-10)ICD-10Covered
    G40.A01Absence epileptic syndrome, not intractable, with status epilepticus.
    G40.A09Absence epileptic syndrome, not intractable, without status epilepticus.
    G40.A11Absence epileptic syndrome, intractable, with status epilepticus.
    G40.A19Absence epileptic syndrome, intractable, without status epilepticus.
    G40.101Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus.
    G40.109Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus.
    G40.111Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus.
    G40.219Complex partial seizures, intractable, without status epilepticus.
    G40.301Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus.
    G40.309Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus.
    1–10 of 33
    1/4
    Minimum age
    FDA‑approved minimum age4 years (member must be 4 years of age or older)
    Policy threshold wordingMember is 4 years of age or older (FDA approved for 4 years old and older)
    Denial risk if missingRequests lacking documentation that patient is ≥4 years may be denied

    Authorization, Documentation, and Provider Requirements

    Prior Authorization

    Prior authorization required for listed procedure and device codes

    Prior authorization is required for implantation, replacement, revision, removal, and device-related HCPCS/CPT codes listed in the policy (including but not limited to 61885, 61886, 64553, 64568, 64569, 64570, L8680–L8688, and 0908T).

    • PA required for implantation and removal procedures (e.g., 61885, 61886, 64553, 64568, 64569, 64570).
    • PA required for device supply codes (e.g., L8680, L8681, L8683, L8685–L8688).
    • PA required for integrated system implantation/replacement code 0908T.
    Step Therapy

    Required trial/failure of therapeutic anti‑epileptic medications

    Before VNS is considered medically necessary, the patient must have tried and failed therapeutic levels of anti‑epileptic medications or be unable to tolerate therapeutic AEDs because of intolerable side effects.

    Background

    A vagus nerve stimulator (VNS) is an implantable pulse generator and lead system connected to the left vagus nerve that delivers programmed intermittent electrical signals as an adjunctive therapy for medically refractory focal/partial‑onset seizures. The generator is implanted subcutaneously near the clavicle and, when appropriately programmed and interrogated, delivers intermittent stimulation to the left cervical vagus nerve to help reduce seizure frequency and severity. Electronic analysis/programming of the implanted neurostimulator is considered medically necessary when the coverage criteria are met.

    Definitions

    Vagus nerve stimulator (VNS)
    Device definitionAn implantable pulse generator and lead system connected to the left vagus nerve that delivers programmed intermittent electrical signals as adjunctive treatment for medically refractory focal/partial‑onset seizures.
    Implantation sitePulse generator is surgically implanted subcutaneously near the collar bone (clavicle) and connected to the left vagus nerve via a lead wire.
    Primary functionDelivers intermittent electrical stimulation to the vagus nerve to help prevent seizure‑related electrical bursts in the brain.
    Analogy for cliniciansFunctions similarly to a cardiac pacemaker but for modulation of neural activity via the vagus nerve.
    Policy Summary
    Payereocco
    PolicyVagus Nerve Stimulation (VNS) — coverage criteria for implantable VNS systems
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateJun 1, 2026
    Last ReviewMay 27, 2026
    Next Review DateMay 27, 2026
    Key ActionObtain prior authorization and submit neurologist records documenting diagnosis, prior medical/surgical treatments, and eligibility (age ≥4 years).
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaCodes, Age Limits, and BillingAuthorization, Documentation, and Provider RequirementsBackgroundDefinitions
  1. Document therapeutic AED trials and either continued seizures despite therapeutic levels or documented intolerance to therapeutic AEDs.
    2. Documentation Required

    Treating neurologist records and history of trials/surgeries must be provided

    Submit medical records from the treating neurologist documenting the diagnosis of partial‑onset seizures and records of medical and surgical treatments tried and failed with the prior authorization request.

    • Documentation should include history of AED trials (doses and therapeutic levels) and any prior surgical interventions (lesionectomy, medial temporal lobectomy) and their outcomes.
    Denial Risk

    Denial risk if key eligibility criteria or documentation are missing

    Requests lacking documentation that the patient is ≥4 years old, has not had a bilateral or left cervical vagotomy, or does not meet medically refractory partial‑onset seizure criteria (including AED trial/failure or intolerance) are at risk for denial.

    • Verify and document patient age (≥4 years).
    • Confirm absence of a bilateral or left cervical vagotomy in the surgical history.
    • Provide evidence of medically refractory partial‑onset seizures per policy criteria (AED trials or documented intolerance).