PA Lookup
If you have questions about prior authorizations, please call:
Member and Recipient Service Line: 1-877-685-2415
Provider Support Service Line: 1-855-250-1539
Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
Authorization Guidelines
Pre-authorization is required for all providers unless performed on the same day as surgery. Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
Pre-authorization is required for all providers unless performed on the same day as surgery.
How to Submit
If applicable, please submit your request to Trillium.
Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed
Authorization Guidelines
Pre-authorization is required for all providers unless performed on the same day as surgery. Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
Pre-authorization is required for all providers unless performed on the same day as surgery.
How to Submit
If applicable, please submit your request to Trillium.
Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming
Authorization Guidelines
Pre-authorization is required for all providers unless performed on the same day as surgery. Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
Pre-authorization is required for all providers unless performed on the same day as surgery.
How to Submit
If applicable, please submit your request to Trillium.
Vagus Nerve Stimulation For the Treatment of Seizures
Approximately 40 percent of all individuals with epilepsy have medically refractory seizures.
Primarily generalized seizures are the most common type of intractable seizures in children;
while in adults, complex partial seizures are the most common intractable seizure type. Medically refractory seizures are those seizures that are not completely controlled by medical therapy. That means that seizures continue to occur despite treatment with a maximally tolerated dose of a firstline anti-epilepsy drug (AED) as monotherapy or in at least one combination with an adjuvant medication. The terms "intractable" or "medically refractory" are interchangeable.
In the past 10 years, significant advances have occurred in surgical treatment for epilepsy and in medical treatment of epilepsy with newly developed and approved medications. Despite these advances, however, 25–50 percent of patients with epilepsy experience breakthrough seizures or suffer from debilitating adverse effects of antiepileptic drugs. Vagus Nerve Stimulation (VNS) has been investigated as a treatment alternative in patients with medically refractory partial-onset seizures for whom surgery is not recommended or for whom surgery has failed.
Vagus Nerve Stimulation (VNS) is performed by an implantable stimulator as a treatment for refractory seizures. VNS treatment sends preprogrammed, intermittent electrical pulses through the vagus nerve in the neck to the brain. These pulses originate in a small generator device that is implanted in the chest. The exact mechanism of the antiepileptic effects of VNS are not fully understood, but the procedure may reduce the severity or the frequency of seizures in selected candidates who have an intact vagus nerve.
Exclusions
Medicaid covers VNS for the treatment of seizures when it is determined to be medically necessary because BOTH of the following criteria are met:
- a. The beneficiary has medically refractory* seizures; AND *Medically refractory means 1. seizures that occur in spite of therapeutic levels of anti-epileptic drugs; OR 2. seizures that cannot be treated with therapeutic levels of antiepileptic drugs because of intolerable adverse side effects.
- b. The beneficiary has failed or is not eligible for surgical treatment.
Additional Service Specifics
Inpatient Hospital, Outpatient Hospital, and Independent Diagnostic Testing Facility (IDTF) for services 95976, 95977, 95983, and 95984.
How to Submit
N/A - No authorization is required
Resources
Vagus Nerve Stimulation For the Treatment of Seizures
Approximately 40 percent of all individuals with epilepsy have medically refractory seizures.
Primarily generalized seizures are the most common type of intractable seizures in children;
while in adults, complex partial seizures are the most common intractable seizure type. Medically refractory seizures are those seizures that are not completely controlled by medical therapy. That means that seizures continue to occur despite treatment with a maximally tolerated dose of a firstline anti-epilepsy drug (AED) as monotherapy or in at least one combination with an adjuvant medication. The terms "intractable" or "medically refractory" are interchangeable.
In the past 10 years, significant advances have occurred in surgical treatment for epilepsy and in medical treatment of epilepsy with newly developed and approved medications. Despite these advances, however, 25–50 percent of patients with epilepsy experience breakthrough seizures or suffer from debilitating adverse effects of antiepileptic drugs. Vagus Nerve Stimulation (VNS) has been investigated as a treatment alternative in patients with medically refractory partial-onset seizures for whom surgery is not recommended or for whom surgery has failed.
Vagus Nerve Stimulation (VNS) is performed by an implantable stimulator as a treatment for refractory seizures. VNS treatment sends preprogrammed, intermittent electrical pulses through the vagus nerve in the neck to the brain. These pulses originate in a small generator device that is implanted in the chest. The exact mechanism of the antiepileptic effects of VNS are not fully understood, but the procedure may reduce the severity or the frequency of seizures in selected candidates who have an intact vagus nerve.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
Exclusions
Medicaid covers VNS for the treatment of seizures when it is determined to be medically necessary because BOTH of the following criteria are met:
- a. The beneficiary has medically refractory* seizures; AND *Medically refractory means 1. seizures that occur in spite of therapeutic levels of anti-epileptic drugs; OR 2. seizures that cannot be treated with therapeutic levels of antiepileptic drugs because of intolerable adverse side effects.
- b. The beneficiary has failed or is not eligible for surgical treatment.
Additional Service Specifics
Inpatient Hospital, Outpatient Hospital, and Independent Diagnostic Testing Facility (IDTF) for services 95976, 95977, 95983, and 95984.
How to Submit
Please submit your request to Trillium Health Resources
Resources
Vagus Nerve Stimulation For the Treatment of Seizures
Approximately 40 percent of all individuals with epilepsy have medically refractory seizures.
Primarily generalized seizures are the most common type of intractable seizures in children;
while in adults, complex partial seizures are the most common intractable seizure type. Medically refractory seizures are those seizures that are not completely controlled by medical therapy. That means that seizures continue to occur despite treatment with a maximally tolerated dose of a firstline anti-epilepsy drug (AED) as monotherapy or in at least one combination with an adjuvant medication. The terms "intractable" or "medically refractory" are interchangeable.
In the past 10 years, significant advances have occurred in surgical treatment for epilepsy and in medical treatment of epilepsy with newly developed and approved medications. Despite these advances, however, 25–50 percent of patients with epilepsy experience breakthrough seizures or suffer from debilitating adverse effects of antiepileptic drugs. Vagus Nerve Stimulation (VNS) has been investigated as a treatment alternative in patients with medically refractory partial-onset seizures for whom surgery is not recommended or for whom surgery has failed.
Vagus Nerve Stimulation (VNS) is performed by an implantable stimulator as a treatment for refractory seizures. VNS treatment sends preprogrammed, intermittent electrical pulses through the vagus nerve in the neck to the brain. These pulses originate in a small generator device that is implanted in the chest. The exact mechanism of the antiepileptic effects of VNS are not fully understood, but the procedure may reduce the severity or the frequency of seizures in selected candidates who have an intact vagus nerve.
Exclusions
Medicaid covers VNS for the treatment of seizures when it is determined to be medically necessary because BOTH of the following criteria are met:
- a. The beneficiary has medically refractory* seizures; AND *Medically refractory means 1. seizures that occur in spite of therapeutic levels of anti-epileptic drugs; OR 2. seizures that cannot be treated with therapeutic levels of antiepileptic drugs because of intolerable adverse side effects.
- b. The beneficiary has failed or is not eligible for surgical treatment.
Additional Service Specifics
Inpatient Hospital, Outpatient Hospital, and Independent Diagnostic Testing Facility (IDTF) for services 95976, 95977, 95983, and 95984.
How to Submit
N/A - No authorization is required
Resources
Incision for implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
How to Submit
N/A - No authorization is required
Incision for implantation of neurostimulator electrode array; neuromuscular
How to Submit
N/A - No authorization is required
Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement)
How to Submit
N/A - No authorization is required
Vagus Nerve Stimulation For the Treatment of Seizures
Approximately 40 percent of all individuals with epilepsy have medically refractory seizures.
Primarily generalized seizures are the most common type of intractable seizures in children;
while in adults, complex partial seizures are the most common intractable seizure type. Medically refractory seizures are those seizures that are not completely controlled by medical therapy. That means that seizures continue to occur despite treatment with a maximally tolerated dose of a firstline anti-epilepsy drug (AED) as monotherapy or in at least one combination with an adjuvant medication. The terms "intractable" or "medically refractory" are interchangeable.
In the past 10 years, significant advances have occurred in surgical treatment for epilepsy and in medical treatment of epilepsy with newly developed and approved medications. Despite these advances, however, 25–50 percent of patients with epilepsy experience breakthrough seizures or suffer from debilitating adverse effects of antiepileptic drugs. Vagus Nerve Stimulation (VNS) has been investigated as a treatment alternative in patients with medically refractory partial-onset seizures for whom surgery is not recommended or for whom surgery has failed.
Vagus Nerve Stimulation (VNS) is performed by an implantable stimulator as a treatment for refractory seizures. VNS treatment sends preprogrammed, intermittent electrical pulses through the vagus nerve in the neck to the brain. These pulses originate in a small generator device that is implanted in the chest. The exact mechanism of the antiepileptic effects of VNS are not fully understood, but the procedure may reduce the severity or the frequency of seizures in selected candidates who have an intact vagus nerve.
Exclusions
Medicaid covers VNS for the treatment of seizures when it is determined to be medically necessary because BOTH of the following criteria are met:
- a. The beneficiary has medically refractory* seizures; AND *Medically refractory means 1. seizures that occur in spite of therapeutic levels of anti-epileptic drugs; OR 2. seizures that cannot be treated with therapeutic levels of antiepileptic drugs because of intolerable adverse side effects.
- b. The beneficiary has failed or is not eligible for surgical treatment.
Additional Service Specifics
Inpatient Hospital, Outpatient Hospital, and Independent Diagnostic Testing Facility (IDTF) for services 95976, 95977, 95983, and 95984.
How to Submit
N/A - No authorization is required
Resources
Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling
Authorization Guidelines
Pre-authorization is required for all providers unless performed on the same day as surgery. Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
Pre-authorization is required for all providers unless performed on the same day as surgery.
How to Submit
If applicable, please submit your request to Trillium.
Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver
How to Submit
N/A - No authorization is required
Deep Brain Stimulation (DBS)
Deep brain stimulation (DBS) consists of electrical stimulation of specific sites in the brain with implanted electrodes to reduce the symptoms of movement disorders such as Parkinson’s disease and Essential Tremor. DBS can be done on one or both sides of the brain, depending on the disorder and the beneficiary's symptoms. Once implanted, noninvasive programming of the stimulator can be adjusted to the patient’s symptoms. This is an important feature for patients, whose disease may progress over time, requiring different stimulation parameters. Setting the best stimulation parameters may involve the balance between optimal symptom control and the appearance of side effects of stimulation, such as dysarthria, disequilibrium, or involuntary movements.
Exclusions
DBS is contraindicated when any of the following are true:
- a. Medical, surgical, neurologic, or orthopedic co-morbidities exist
contraindicating DBS surgery or stimulation.
- b. One or more medical conditions exist that require repeated magnetic
resonance imaging (MRI). MRI can be safely performed under specialized protocols.
- c. Cognitive impairment, dementia, or depression would be worsened by or
would interfere with the beneficiary’s ability to benefit from DBS.
- d. Botulinum toxin injections have been given within the last 4 months.
- e. Diathermy will be used in the future.
Place of Service
Inpatient, Outpatient, and Independent Diagnostic Testing Facilities (IDTF). CPT codes 95970, 95976 and 95977 may be billed in the office setting. CPT codes 95976 and 95977 may be billed in IDTF Centers.
How to Submit
N/A - No authorization is required
Resources
Deep Brain Stimulation (DBS)
Deep brain stimulation (DBS) consists of electrical stimulation of specific sites in the brain with implanted electrodes to reduce the symptoms of movement disorders such as Parkinson’s disease and Essential Tremor. DBS can be done on one or both sides of the brain, depending on the disorder and the beneficiary's symptoms. Once implanted, noninvasive programming of the stimulator can be adjusted to the patient’s symptoms. This is an important feature for patients, whose disease may progress over time, requiring different stimulation parameters. Setting the best stimulation parameters may involve the balance between optimal symptom control and the appearance of side effects of stimulation, such as dysarthria, disequilibrium, or involuntary movements.
Exclusions
DBS is contraindicated when any of the following are true:
- a. Medical, surgical, neurologic, or orthopedic co-morbidities exist
contraindicating DBS surgery or stimulation.
- b. One or more medical conditions exist that require repeated magnetic
resonance imaging (MRI). MRI can be safely performed under specialized protocols.
- c. Cognitive impairment, dementia, or depression would be worsened by or
would interfere with the beneficiary’s ability to benefit from DBS.
- d. Botulinum toxin injections have been given within the last 4 months.
- e. Diathermy will be used in the future.
Place of Service
Inpatient, Outpatient, and Independent Diagnostic Testing Facilities (IDTF). CPT codes 95970, 95976 and 95977 may be billed in the office setting. CPT codes 95976 and 95977 may be billed in IDTF Centers.
How to Submit
N/A - No authorization is required
Resources
Deep Brain Stimulation (DBS)
Deep brain stimulation (DBS) consists of electrical stimulation of specific sites in the brain with implanted electrodes to reduce the symptoms of movement disorders such as Parkinson’s disease and Essential Tremor. DBS can be done on one or both sides of the brain, depending on the disorder and the beneficiary's symptoms. Once implanted, noninvasive programming of the stimulator can be adjusted to the patient’s symptoms. This is an important feature for patients, whose disease may progress over time, requiring different stimulation parameters. Setting the best stimulation parameters may involve the balance between optimal symptom control and the appearance of side effects of stimulation, such as dysarthria, disequilibrium, or involuntary movements.
Exclusions
DBS is contraindicated when any of the following are true:
- a. Medical, surgical, neurologic, or orthopedic co-morbidities exist
contraindicating DBS surgery or stimulation.
- b. One or more medical conditions exist that require repeated magnetic
resonance imaging (MRI). MRI can be safely performed under specialized protocols.
- c. Cognitive impairment, dementia, or depression would be worsened by or
would interfere with the beneficiary’s ability to benefit from DBS.
- d. Botulinum toxin injections have been given within the last 4 months.
- e. Diathermy will be used in the future.
Place of Service
Inpatient, Outpatient, and Independent Diagnostic Testing Facilities (IDTF). CPT codes 95970, 95976 and 95977 may be billed in the office setting. CPT codes 95976 and 95977 may be billed in IDTF Centers.
How to Submit
N/A - No authorization is required
Resources
Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch
Authorization Guidelines
Pre-authorization is required for all providers unless performed on the same day as surgery. Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
Pre-authorization is required for all providers unless performed on the same day as surgery.
How to Submit
If applicable, please submit your request to Trillium.
Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale
How to Submit
N/A - No authorization is required
Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring
How to Submit
N/A - No authorization is required
Chemodenervation of parotid and submandibular salivary glands, bilateral
How to Submit
N/A - No authorization is required
Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm)
How to Submit
N/A - No authorization is required
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