PA Lookup

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

• a. Examinations using portable hand-held devices;
• b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
• c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
• d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
• e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
• f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
• g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-27
• Records Management and Documentation Manual

Visual Evoked Potential (VEP) test is a diagnostic tool for the neurological assessment of the visual system. VEP measures the time it takes for nerves to respond to stimulation. The size of the response is also measured. During the VEP test, the eyes are stimulated by looking at a test pattern. Each type of response is recorded from brain waves by using electrodes taped to the head. The VEP test is the most commonly used evoked potential test in the diagnosis of multiple sclerosis (MS). Interpretation is provided by neurologists, physiatrists, ophthalmologists or optometrists specially trained or skilled in VEP testing. The VEP test involves a flashing stroboscope or viewing a black and white checkered pattern on a television (TV) monitor in a darkened room. The black and white squares alternate on a regular cycle which generates electrical potentials along the optic nerve and into the brain producing wave patterns that are recorded. These are detected with electroencephalographical (EEG) sensors placed at specific sites on the back of the head (the occipital scalp). Each eye is tested independently while an eye patch is worn on the other eye. VEPs are very sensitive at measuring slowed responses to visual events and can often detect dysfunction which is undetectable through clinical evaluation and the person is unaware of any visual defects. Because of their ability to detect silent lesions and historic demyelinating episodes, they are very useful diagnostic tools. A definite diagnosis of multiple sclerosis requires at least two distinct demyelinating episodes, in two different central nervous system sites which are separated by at least one month (the Schumacher criteria). VEPs can often provide evidence of such episodes when other tests, even MRI, cannot.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Unit Value

1 unit per test

Limits

VEP is considered experimental and investigational if the Clinical Coverage Policy eligibility criteria are not met (section 2.0 and 3.0)

Exclusions

Medicaid does not cover VEP as a routine screening tool to meet the requirements of vision screening during an Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) exam. However, if during an EPSDT exam the physician documents a medical need for additional vision services, (i.e. an abnormality is suspected) the physician is expected to make the appropriate referral for a more formal vision assessment. Physicians providing children’s vision assessments shall follow the American Academy of Pediatrics policy for “Eye Examination in Infants, Children, and Young Adults by Pediatricians.”

Place of Service

Inpatient, Outpatient, Office and Independent Diagnostic Testing Facilities (IDTF)

Additional Service Specifics

Use modifier 26 when billing the professional component. Use modifier TC when billing the technical component.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-28
• Records Management and Documentation Manual

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

12 per day

Exclusions

• a. Examinations using portable hand-held devices;
• b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
• c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
• d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
• e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
• f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
• g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-27
• Records Management and Documentation Manual

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

20 per day

Exclusions

• a. Examinations using portable hand-held devices;
• b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
• c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
• d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
• e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
• f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
• g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-27
• Records Management and Documentation Manual

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

5 hours without records

Exclusions

• a. Examinations using portable hand-held devices;
• b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
• c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
• d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
• e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
• f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
• g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-27
• Records Management and Documentation Manual

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.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

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

• Clinical Coverage Policy No: 1A-26
• Records Management and Documentation Manual

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.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

Code 95962 may be billed up to an additional 7 units per date of service when billed with the primary procedure.

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

• Clinical Coverage Policy No: 1A-26
• Records Management and Documentation Manual

Spinal cord stimulation (SCS), also known as a dorsal column stimulator, is an implantable medical device used to treat chronic intractable neuropathic pain. A small wire (called a lead) connected to a power source is surgically implanted under the skin. Low-level electrical signals are then transmitted through the lead to the spinal cord or to specific nerves to block pain signals from reaching the brain. Using a remote control, a patient can turn the current on and off, or adjust the intensity. The sensations, or paresthesias, derived from the stimulator are different for everyone. Most patients describe it as a pleasant tingling sensation, subsequently altering the perception of pain and providing analgesia. Implantation of the spinal cord stimulator is typically a two-step process. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed, defined as at least 50% reduction in pain, the electrodes and radio receiver/transducer are permanently implanted. This is a reversible therapy and results in no intended neuroablation, or nerve destruction.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See Evolent site for specific requirements

Limits

Trial stimulation must use a temporarily implanted electrode for a minimum of 48 hours before permanent implantation. Billing units: one unit per date of service for the applicable procedure codes.

Exclusions

SCS is not covered and may be considered investigational for all other indications, including treatment of the following:

• a. Critical limb ischemia as a technique to forestall amputation.
• b. Visceral pain.
• c. Drug-refractory chronic cluster headaches.
• d. Nociceptive pain (resulting from irritation, not damage to the nerves).
• e. Central deafferentation pain (related to central nervous system damage from a stroke or spinal cord injury).
• f. Pregnant beneficiaries.
• g. Chronic refractory angina pectoris.

Place of Service

Inpatient, Outpatient. 95970 through 95973 may also be billed in the office setting.

How to Submit

Please submit your request to Evolent

• https://www1.radmd.com/all-health-plans/trillium-health-resources

Resources

• Clinical Coverage Policy No: 1A-25
• Records Management and Documentation Manual

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.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

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

• Clinical Coverage Policy No: 1A-26
• Records Management and Documentation Manual

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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See Evolent site for specific requirements

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 Evolent

• https://www1.radmd.com/all-health-plans/trillium-health-resources

Resources

• Clinical Coverage Policy No.:1A-33
• Records Management and Documentation Manual

Spinal cord stimulation (SCS), also known as a dorsal column stimulator, is an implantable medical device used to treat chronic intractable neuropathic pain. A small wire (called a lead) connected to a power source is surgically implanted under the skin. Low-level electrical signals are then transmitted through the lead to the spinal cord or to specific nerves to block pain signals from reaching the brain. Using a remote control, a patient can turn the current on and off, or adjust the intensity. The sensations, or paresthesias, derived from the stimulator are different for everyone. Most patients describe it as a pleasant tingling sensation, subsequently altering the perception of pain and providing analgesia. Implantation of the spinal cord stimulator is typically a two-step process. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed, defined as at least 50% reduction in pain, the electrodes and radio receiver/transducer are permanently implanted. This is a reversible therapy and results in no intended neuroablation, or nerve destruction.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See Evolent site for specific requirements

Limits

Trial stimulation must use a temporarily implanted electrode for a minimum of 48 hours before permanent implantation. Billing units: one unit per date of service for the applicable procedure codes.

Exclusions

SCS is not covered and may be considered investigational for all other indications, including treatment of the following:

• a. Critical limb ischemia as a technique to forestall amputation.
• b. Visceral pain.
• c. Drug-refractory chronic cluster headaches.
• d. Nociceptive pain (resulting from irritation, not damage to the nerves).
• e. Central deafferentation pain (related to central nervous system damage from a stroke or spinal cord injury).
• f. Pregnant beneficiaries.
• g. Chronic refractory angina pectoris.

Place of Service

Inpatient, Outpatient. 95970 through 95973 may also be billed in the office setting.

How to Submit

Please submit your request to Evolent

• https://www1.radmd.com/all-health-plans/trillium-health-resources

Resources

• Clinical Coverage Policy No: 1A-25
• Records Management and Documentation Manual

Spinal cord stimulation (SCS), also known as a dorsal column stimulator, is an implantable medical device used to treat chronic intractable neuropathic pain. A small wire (called a lead) connected to a power source is surgically implanted under the skin. Low-level electrical signals are then transmitted through the lead to the spinal cord or to specific nerves to block pain signals from reaching the brain. Using a remote control, a patient can turn the current on and off, or adjust the intensity. The sensations, or paresthesias, derived from the stimulator are different for everyone. Most patients describe it as a pleasant tingling sensation, subsequently altering the perception of pain and providing analgesia. Implantation of the spinal cord stimulator is typically a two-step process. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed, defined as at least 50% reduction in pain, the electrodes and radio receiver/transducer are permanently implanted. This is a reversible therapy and results in no intended neuroablation, or nerve destruction.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See Evolent site for specific requirements

Limits

Trial stimulation must use a temporarily implanted electrode for a minimum of 48 hours before permanent implantation. Billing units: one unit per date of service for the applicable procedure codes.

Exclusions

SCS is not covered and may be considered investigational for all other indications, including treatment of the following:

• a. Critical limb ischemia as a technique to forestall amputation.
• b. Visceral pain.
• c. Drug-refractory chronic cluster headaches.
• d. Nociceptive pain (resulting from irritation, not damage to the nerves).
• e. Central deafferentation pain (related to central nervous system damage from a stroke or spinal cord injury).
• f. Pregnant beneficiaries.
• g. Chronic refractory angina pectoris.

Place of Service

Inpatient, Outpatient. 95970 through 95973 may also be billed in the office setting.

How to Submit

Please submit your request to Evolent

• https://www1.radmd.com/all-health-plans/trillium-health-resources

Resources

• Clinical Coverage Policy No: 1A-25
• Records Management and Documentation Manual

Spinal cord stimulation (SCS), also known as a dorsal column stimulator, is an implantable medical device used to treat chronic intractable neuropathic pain. A small wire (called a lead) connected to a power source is surgically implanted under the skin. Low-level electrical signals are then transmitted through the lead to the spinal cord or to specific nerves to block pain signals from reaching the brain. Using a remote control, a patient can turn the current on and off, or adjust the intensity. The sensations, or paresthesias, derived from the stimulator are different for everyone. Most patients describe it as a pleasant tingling sensation, subsequently altering the perception of pain and providing analgesia. Implantation of the spinal cord stimulator is typically a two-step process. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed, defined as at least 50% reduction in pain, the electrodes and radio receiver/transducer are permanently implanted. This is a reversible therapy and results in no intended neuroablation, or nerve destruction.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See Evolent site for specific requirements

Limits

Trial stimulation must use a temporarily implanted electrode for a minimum of 48 hours before permanent implantation. Billing units: one unit per date of service for the applicable procedure codes.

Exclusions

SCS is not covered and may be considered investigational for all other indications, including treatment of the following:

• a. Critical limb ischemia as a technique to forestall amputation.
• b. Visceral pain.
• c. Drug-refractory chronic cluster headaches.
• d. Nociceptive pain (resulting from irritation, not damage to the nerves).
• e. Central deafferentation pain (related to central nervous system damage from a stroke or spinal cord injury).
• f. Pregnant beneficiaries.
• g. Chronic refractory angina pectoris.

Place of Service

Inpatient, Outpatient. 95970 through 95973 may also be billed in the office setting.

How to Submit

Please submit your request to Evolent

• https://www1.radmd.com/all-health-plans/trillium-health-resources

Resources

• Clinical Coverage Policy No: 1A-25
• Records Management and Documentation Manual

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.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

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

• Clinical Coverage Policy No: 1A-26
• Records Management and Documentation Manual

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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

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

• Clinical Coverage Policy No.:1A-33
• Records Management and Documentation Manual

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.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

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

• Clinical Coverage Policy No: 1A-26
• Records Management and Documentation Manual

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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

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

• Clinical Coverage Policy No.:1A-33
• Records Management and Documentation Manual

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required