Anthem Blue Cross and Blue Shield Virginia policy
CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems is a public Anthem Blue Cross and Blue Shield Virginia policy (policy CG-MED-79). It lists 21 CPT or HCPCS codes, 20 of them on the Anthem Blue Cross and Blue Shield Virginia prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- CG-MED-79
- 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 and Blue Shield Virginia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross and Blue Shield Virginia policies |
|---|---|---|---|
| 33276 | On the list | Insertion of phrenic nerve stimulator system (pulse generator and stimulating lead[s]), including vessel catheterization, all imaging guidance, and pulse generator initial ana | Policies naming 33276 |
| 33277 | On the list | Insertion of phrenic nerve stimulator transvenous sensing lead (List separately in addition to code for primary procedure) | Policies naming 33277 |
| 33278 | On the list | Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; system, including pulse generat | Policies naming 33278 |
| 33279 | On the list | Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sens | Policies naming 33279 |
| 33280 | On the list | Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator only | Policies naming 33280 |
| 33281 | On the list | Repositioning of phrenic nerve stimulator transvenous lead(s) | Policies naming 33281 |
| 33287 | On the list | Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator | Policies naming 33287 |
| 33288 | On the list | Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous sti | Policies naming 33288 |
| 64575 | On the list | Open implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) | Policies naming 64575 |
| 64590 | On the list | Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pu | Policies naming 64590 |
| 93150 | On the list | Therapy activation of implanted phrenic nerve stimulator system, including all interrogation and programming | Policies naming 93150 |
| 93151 | On the list | Interrogation and programming (minimum one parameter) of implanted phrenic nerve stimulator system | Policies naming 93151 |
| 93152 | On the list | Interrogation and programming of implanted phrenic nerve stimulator system during polysomnography | Policies naming 93152 |
| 93153 | On the list | Interrogation without programming of implanted phrenic nerve stimulator system | Policies naming 93153 |
| C1778 | On the list | Lead, neurostimulator (implantable) | Policies naming C1778 |
| C1816 | On the list | Receiver and/or transmitter, neurostimulator (implantable) | Policies naming C1816 |
| C1823 | On the list | Generator, neurostimulator (implantable), non-rechargeable, with transvenous sensing and stimulation leads | Policies naming C1823 |
| L8680 | On the list | Implantable neurostimulator electrode, each | Policies naming L8680 |
| L8682 | On the list | Implantable neurostimulator radiofrequency receiver | Policies naming L8682 |
| L8683 | On the list | Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver | Policies naming L8683 |
| L8697 | Not listed | Policies naming L8697 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list