Anthem Blue Cross Blue Shield of California policy
CG-SURG-126 Tibial Nerve Stimulation
CG-SURG-126 Tibial Nerve Stimulation is a public Anthem Blue Cross Blue Shield of California policy (policy CG-SURG-126). It lists 12 CPT or HCPCS codes, 8 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-126
- 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 |
|---|---|---|---|
| 0587T | Not listed | Policies naming 0587T | |
| 0588T | Not listed | Policies naming 0588T | |
| 0816T | On the list | Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (e.g., array or leadless), and pulse generator or receiver, including analysis, programming, and imaging guidance, when performed, posterior tibial nerve; subcutaneous | Policies naming 0816T |
| 0817T | On the list | Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (e.g., array or leadless), and pulse generator or receiver, including analysis, programming, and imaging guidance, when performed, posterior tibial nerve; subfascial | Policies naming 0817T |
| 0818T | On the list | Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subcutaneous | Policies naming 0818T |
| 0819T | On the list | Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subfascial | Policies naming 0819T |
| 0988T | Not listed | Policies naming 0988T | |
| 0989T | Not listed | Policies naming 0989T | |
| 64566 | On the list | Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming | Policies naming 64566 |
| A4545 | On the list | Supplies and accessories for external tibial nerve stimulator (e.g., socks, gel pads, electrodes, etc.), needed for one month [e.g., supplies for Vivally and ZIDA systems] | Policies naming A4545 |
| E0736 | On the list | Transcutaneous tibial nerve stimulator [e.g., ZIDA Wearable Neuromodulation control unit, Vivally System with hardware control unit] | Policies naming E0736 |
| E0737 | On the list | Transcutaneous tibial nerve stimulator, controlled by phone application [e.g., Vivally System, smartphone] | Policies naming E0737 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list