Effective Date:
a) This policy will apply to all services performed on or after the above revision date which will become the new effective date.
b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.
The vast majority of patients who have epilepsy can be controlled by conventional drug therapy. However some patients in spite of adequate dosage of anti-epilepsy drugs continue to have seizures. Vagus nerve stimulation (VNS) has been shown to shorten the duration and reduce the severity of seizures in certain patients who remain refractory despite optimal drug therapy or surgical intervention or in those with debilitating side effects of anti-epileptic medications.
Vagus Nerve Stimulation is not covered for other uses.
Vagus Nerve Stimulation requires pre certification.
Vagus nerve electrical stimulators (the NeuroCybernetic Prosthesis System) are considered medically necessary in members with partial onset seizures who remain refractory (G40.011-G40.019, G40.111-G40.119, and G40.211-G40.219) to:
Hayes B for patients > 12
Codes Used In This BI:
61885 Insertion/replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; w/connection to a single electrode array
64553 Percutaneous implantation of neurostimulator electrode array; cranial nerve
64568 Incision for implantation of cranial nerve neurostimulator electrode array and pulse generator
Vagus nerve stimulators are considered experimental and investigational for the treatment of all other indications, including autism, obesity, refractory depression and cognitive impairment associated with Alzheimer`s disease, and obsessive-compulsive disorder because its effectiveness for these indications has not been established.