Anthem Blue Cross Blue Shield of California policy
Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices is a public Anthem Blue Cross Blue Shield of California policy (policy DME.00011). It lists 15 CPT or HCPCS codes, 15 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- DME.00011
- 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 Blue Shield of California prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of California policies |
|---|---|---|---|
| 0278T | On the list | Transcutaneous electrical modulation pain reprocessing (e.g., scrambler therapy), each treatment session (includes placement of electrodes) | Policies naming 0278T |
| 0766T | On the list | Transcutaneous magnetic stimulation by focused low- frequency electromagnetic pulse, peripheral nerve, with identification and marking of the treatment location, including noninvasive electroneurographic localization (nerve conduction localization), when performed; first nerve | Policies naming 0766T |
| 0767T | On the list | Transcutaneous magnetic stimulation by focused low- frequency electromagnetic pulse, peripheral nerve, with identification and marking of the treatment location, including noninvasive electroneurographic localization (nerve conduction localization), when performed; each additional nerve | Policies naming 0767T |
| 1088T | On the list | Percutaneous application of high-frequency neuromodulation signals using microneedle electrode array for the treatment of nociceptive or neuropathic pain, including electrode placement and patient training, per day | Policies naming 1088T |
| 64999 | On the list | Unlisted procedure, nervous system [when specified as implantation, revision, replacement, or removal of vagus nerve blocking neurostimulator electrode array or pulse generator at the esophagogastric junction] or [when specified as percutaneous neuromodulation therapy] or [when specified as introduction of Kebilidi into cranial cavity and brain] or [when specified as craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebellar] or [when specified as percutaneous decompression or laser procedures of cervical or thoracic spine] or [when specified as epiduroscopy] or [when specified as pulsed radiofrequency treatment] or [when specified as cooled or pulsed RF therapy (not destruction) to genicular nerve(s)] or [when specified as cryoneurolysis] or [when specified as nanoparticle thermal ablation] or [when specified as adrenal tissue, fetal mesencephalic tissue or fetal xenograft tissue transplant to brain] or [when specified as harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | Policies naming 64999 |
| A4596 | On the list | Cranial electrotherapy stimulation (CES) system supplies and accessories, per month | Policies naming A4596 |
| E0732 | On the list | Cranial electrotherapy stimulation (CES) system, any type | Policies naming E0732 |
| E0761 | On the list | Non-thermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device | Policies naming E0761 |
| E0762 | On the list | Transcutaneous electrical joint stimulation device system, includes all accessories (PES) | Policies naming E0762 |
| E0765 | On the list | FDA approved nerve stimulator, for treatment of nausea and vomiting [e.g., Reliefband® neuromodulation stimulator] | Policies naming E0765 |
| E0769 | On the list | Electrical stimulation or electromagnetic wound treatment device, not otherwise classified | Policies naming E0769 |
| E1399 | On the list | Durable medical equipment, miscellaneous | Policies naming E1399 |
| S8130 | On the list | Interferential current stimulator, 2 channel | Policies naming S8130 |
| S8131 | On the list | Interferential current stimulator, 4 channel | Policies naming S8131 |
| S8930 | On the list | Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with the patient | Policies naming S8930 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list