Anthem Blue Cross Blue Shield of California policy
CG-SURG-120 Vagus Nerve Stimulation
CG-SURG-120 Vagus Nerve Stimulation is a public Anthem Blue Cross Blue Shield of California policy (policy CG-SURG-120). It lists 21 CPT or HCPCS codes, 19 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- CG-SURG-120
- 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 Blue Shield of California prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of California policies |
|---|---|---|---|
| 0908T | On the list | Open implantation of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed | Policies naming 0908T |
| 0909T | On the list | Replacement of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed | Policies naming 0909T |
| 0910T | On the list | Removal of integrated neurostimulation system, vagus nerve | Policies naming 0910T |
| 0911T | On the list | Electronic analysis of implanted integrated neurostimulation system, vagus nerve; without programming by physician or other qualified health care professional | Policies naming 0911T |
| 0912T | On the list | Electronic analysis of implanted integrated neurostimulation system, vagus nerve; with simple programming by physician or other qualified health care professional | Policies naming 0912T |
| 61885 | On the list | Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array | Policies naming 61885 |
| 64553 | On the list | Percutaneous implantation of neurostimulator electrodes; cranial nerve | Policies naming 64553 |
| 64568 | On the list | Open implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator | Policies naming 64568 |
| 64569 | On the list | Revision or replacement of cranial nerve (e.g., vagus nerve) neurostimulator electrode array, including connection to existing pulse generator | Policies naming 64569 |
| 95976 | On the list | Electronic analysis of implanted neurostimulator pulse generator/transmitter (e.g., contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple cranial nerve neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional | Policies naming 95976 |
| 95977 | On the list | Electronic analysis of implanted neurostimulator pulse generator/transmitter (e.g., contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex cranial nerve neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional | Policies naming 95977 |
| C1607 | On the list | Neurostimulator, integrated (implantable), rechargeable with all implantable and external components including charging system | Policies naming C1607 |
| C1767 | On the list | Generator, neurostimulator (implantable), nonrechargeable | Policies naming C1767 |
| C1778 | On the list | Lead, neurostimulator (implantable) | Policies naming C1778 |
| C1826 | Not listed | Policies naming C1826 | |
| C1827 | Not listed | Policies naming C1827 | |
| E1399 | On the list | Durable medical equipment, miscellaneous | Policies naming E1399 |
| L8679 | On the list | Neurostimulator Implantation - Implantable neurostimulator, pulse generator, any type | Policies naming L8679 |
| L8680 | On the list | Neurostimulator Implantation - Implantable heurostimulator electrode, each | Policies naming L8680 |
| 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 Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list