Anthem Blue Cross and Blue Shield Virginia policy
CG-SURG-126 Tibial Nerve Stimulation
CG-SURG-126 Tibial Nerve Stimulation is a public Anthem Blue Cross and Blue Shield Virginia policy (policy CG-SURG-126). It lists 12 CPT or HCPCS codes, 8 of them on the Anthem Blue Cross and Blue Shield Virginia prior authorization list. Not a coverage decision; the payer's own document governs.
Check eligibility for free
No account required. Sign a BAA to see plan details, coordination of benefits and more
- Policy number
- CG-SURG-126
- 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 |
|---|---|---|---|
| 0587T | Not listed | Policies naming 0587T | |
| 0588T | Not listed | Policies naming 0588T | |
| 0816T | On the list | Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (eg, array or leadless), and pulse generator or receiver, in | Policies naming 0816T |
| 0817T | On the list | Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (eg, array or leadless), and pulse generator or receiver, in | Policies naming 0817T |
| 0818T | On the list | Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subcut | Policies naming 0818T |
| 0819T | On the list | Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subfas | Policies naming 0819T |
| 0988T | Not listed | Policies naming 0988T | |
| 0989T | Not listed | Policies naming 0989T | |
| 64566 | On the list | Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming | Policies naming 64566 |
| A4545 | On the list | Supplies and accessories for external tibial nerve stimulator (e.g., socks, gel pads, electrodes, etc.), needed for one month | Policies naming A4545 |
| E0736 | On the list | Transcutaneous tibial nerve stimulator | Policies naming E0736 |
| E0737 | On the list | Transcutaneous tibial nerve stimulator, controlled by phone application | Policies naming E0737 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list