Anthem Blue Cross and Blue Shield Virginia policy
Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence
Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence is a public Anthem Blue Cross and Blue Shield Virginia policy (policy CG-SURG-95). It lists 19 CPT or HCPCS codes, 16 of them on the Anthem Blue Cross and Blue Shield Virginia prior authorization list. Not a coverage decision; the payer's own document governs.
- Policy number
- CG-SURG-95
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross and Blue Shield Virginia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross and Blue Shield Virginia policies |
|---|---|---|---|
| 0786T | Not listed | Policies naming 0786T | |
| 0787T | On the list | Revision or removal of neurostimulator electrode array, sacral, with integrated neurostimulator | Policies naming 0787T |
| 63185 | On the list | Laminectomy with rhizotomy; 1 or 2 segments | Policies naming 63185 |
| 63190 | On the list | Laminectomy with rhizotomy; more than 2 segments | Policies naming 63190 |
| 63655 | On the list | Laminectomy, Implantation, Neurostimulator Electrodes, Plate/Paddle, Epidural | Policies naming 63655 |
| 64561 | On the list | Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed | Policies naming 64561 |
| 64581 | On the list | Open implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) | Policies naming 64581 |
| 64585 | On the list | Revision or removal of peripheral neurostimulator electrode array | Policies naming 64585 |
| 64590 | On the list | Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pu | Policies naming 64590 |
| 64595 | Not listed | Policies naming 64595 | |
| C1767 | On the list | Generator, neurostimulator (implantable), nonrechargeable | Policies naming C1767 |
| C1820 | On the list | Generator, neurostimulator (implantable), with rechargeable battery and charging system | Policies naming C1820 |
| C1883 | On the list | Adaptor/extension, pacing lead or neurostimulator lead (implantable) | Policies naming C1883 |
| L8679 | On the list | Implantable neurostimulator, pulse generator, any type | Policies naming L8679 |
| L8680 | On the list | Implantable neurostimulator electrode, each | Policies naming L8680 |
| L8682 | On the list | Implantable neurostimulator radiofrequency receiver | Policies naming L8682 |
| L8684 | Not listed | Policies naming L8684 | |
| L8685 | On the list | Implantable neurostimulator pulse generator, single array, rechargeable, includes extension | Policies naming L8685 |
| L8686 | On the list | Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension | Policies naming L8686 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list