Anthem Blue Cross Blue Shield of California prior authorization 64590

Anthem Blue Cross Blue Shield of California prior authorization for 64590: Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver [when specified as phrenic nerve stimulator for CG-MED-79] or [when specified as sacral nerve stimulator for CG-SURG-95]

Code

64590

Description

Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver [when specified as phrenic nerve stimulator for CG-MED-79] or [when specified as sacral nerve stimulator for CG-SURG-95]

Source

California PPO Prior Authorization List, Pg 43 Original policy

Anthem Blue Cross Blue Shield of California prior authorization