Anthem Blue Cross and Blue Shield Virginia policy
SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)
SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures) is a public Anthem Blue Cross and Blue Shield Virginia policy (policy SURG.00112). It lists 18 CPT or HCPCS codes, 12 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
- SURG.00112
- 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 |
|---|---|---|---|
| 1057T | Not listed | Policies naming 1057T | |
| 1058T | Not listed | Policies naming 1058T | |
| 1059T | Not listed | Policies naming 1059T | |
| 1060T | Not listed | Policies naming 1060T | |
| 1061T | Not listed | Policies naming 1061T | |
| 61885 | On the list | Subq Placement Cranial Neurostimulator Pulse Generator/Receiver; W/Connection Sngle Electrod Array | Policies naming 61885 |
| 64553 | On the list | Percutaneous implantation of neurostimulator electrode array; cranial nerve | Policies naming 64553 |
| 64555 | On the list | Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) | Policies naming 64555 |
| 64568 | Not listed | Policies naming 64568 | |
| 64569 | On the list | Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator | Policies naming 64569 |
| 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 |
| C1767 | On the list | Generator, neurostimulator (implantable), nonrechargeable | Policies naming C1767 |
| C1778 | On the list | Lead, neurostimulator (implantable) | Policies naming C1778 |
| L8679 | On the list | Implantable neurostimulator, pulse generator, any type | Policies naming L8679 |
| L8680 | On the list | Implantable neurostimulator electrode, each | Policies naming L8680 |
| L8685 | On the list | Implantable neurostimulator pulse generator, single array, rechargeable, includes extension | Policies naming L8685 |
| L8686 | On the list | Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension | Policies naming L8686 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list