CurrentUnitedHealthcarePolicy CSNCT0101.07

Vagus and External Trigeminal Nerve Stimulation (for North Carolina Only)

UnitedHealthcare medical policy applying only to North Carolina that references state Medicaid clinical coverage policy for vagus nerve stimulation for seizures, lists applicable procedure and supply codes, documents medical record requirements, and provides FDA/device information and related policies. Coverage clinical criteria are governed by North Carolina Medicaid policy (Physician: 1A-33).

Policy Summary

PayerUnitedHealthcare

PolicyVagus and External Trigeminal Nerve Stimulation (for North Carolina Only)

Policy CodePolicy CSNCT0101.07

Change TypeDocumentation & related links updated

Effective DateDec 1, 2025

Next Review DateN/A

Key ActionDocument relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures in the patient's medical record to support medical necessity; make records available upon request.

SourceLink

POLICY UPDATE CHANGES

04/01/2026 - Updated related policies link for Transcranial Magnetic Stimulation for Treating Physical Health Conditions (for North Carolina Only).

12/01/2025 - Added detailed language to 'Medical Records Documentation Used for Reviews' specifying documentation requirements and that documentation may be required to assess clinical criteria.

North Carolina-onlyGeographic Scope

NC Medicaid 1A-33Primary Clinical Criteria Source

~11Referenced Codes

Coverage Summary

This UnitedHealthcare medical policy, CSNCT0101.07, addresses Vagus and External Trigeminal Nerve Stimulation and applies only to North Carolina. Coverage determinations reference and defer to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Physician: 1A-33, for medical necessity clinical criteria. The policy is effective December 1, 2025 and was last reviewed/updated on April 1, 2026.

Key Facts

Geographic ScopeNorth Carolina-only

Primary Clinical Criteria SourceReferences NC Medicaid 1A-33

Referenced Codes~11

Policy numberCSNCT0101.07

Effective DateDecember 1, 2025

Last Review04/01/2026

Medical Necessity

Coverage / Medical Necessity

Refer to North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Physician: 1A-33, Vagus Nerve Stimulation for the Treatment of Seizures for medical necessity clinical coverage criteria.

ALL of the following

Defer to NC Medicaid Clinical Coverage Policy: This UnitedHealthcare Medical Policy applies only to the state of North Carolina and defers to the North Carolina Medicaid clinical coverage policy (Physician: 1A-33) for medical necessity criteria for vagus nerve stimulation for treatment of seizures.
See North Carolina Medicaid Clinical Coverage Policy Physician: 1A-33 for detailed medical necessity criteria.
Medical Records Documentation: Medical records documentation must fully support medical necessity and may be required to assess whether member meets clinical criteria; documentation should include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, be legible, maintained in the patient's medical record, and made available upon request.
Documentation requirements added 12/01/2025.

Coding

CPT / Procedure Codes (reference)CPT

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
64553	Percutaneous implantation of neurostimulator electrode array; cranial nerve
64568	Open implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator
64570	Removal of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator

HCPCS / DME and Implantable Device Codes (reference)HCPCS

E0770	Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified
E1399	Durable medical equipment, miscellaneous
L8679	Implantable neurostimulator, pulse generator, any type
L8680	Implantable neurostimulator electrode, each
L8682	Implantable neurostimulator radiofrequency receiver
L8683	Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
L8685	Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
L8686	Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension
L8687	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
L8688	Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension

Provider Actions

Documentation Required

Maintain supporting medical records

Document relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures in the patient's medical record to support medical necessity; make records available upon request.

Includes but is not limited to relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; must support medical necessity and be made available upon request.

Prior Authorization

Refer to state Medicaid clinical criteria for prior authorization

For North Carolina members, clinical coverage/medical necessity determinations should follow North Carolina Medicaid Clinical Coverage Policy Physician: 1A-33; coverage is dependent on federal, state, or contractual requirements which may impose prior authorization or coverage mandates.

Background and Regulatory Information

This policy provides assistance in interpreting UnitedHealthcare standard benefit plans for vagus nerve stimulation and external trigeminal nerve stimulation in North Carolina and explicitly defers to the North Carolina Medicaid clinical coverage policy (Physician: 1A-33) for medical necessity determinations. Medical records documentation must fully support medical necessity and may be requested to assess whether a member meets clinical criteria; documentation should include, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, be legible, maintained in the patient's medical record, and made available upon request.

FDA device approvals for implantable and transcutaneous vagus nerve stimulators and for external/transcutaneous trigeminal nerve stimulation are listed in the policy for informational purposes only and are not by themselves a basis for coverage. The policy also provides links to related UnitedHealthcare policies.

Medical records documentationIncludes but is not limited to relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; must support medical necessity and be made available upon request.

Revision History

2026-04-01revisedLatest

Reference link updated to reflect current policy title.

2025-12-01added

Added detailed language to Medical Records Documentation specifying documentation requirements (relevant medical history, physical examination, pertinent diagnostic test results), that documentation must be legible, maintained in the patient's medical record, and made available upon request.

2025-12-01effective

Policy effective date.