Anthem Blue Cross Blue Shield of California policy
Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence
Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence is a public Anthem Blue Cross Blue Shield of California policy (policy CG-SURG-95). It lists 19 CPT or HCPCS codes, 17 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
- CG-SURG-95
- 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 |
|---|---|---|---|
| 0786T | Not listed | Policies naming 0786T | |
| 0787T | On the list | Revision or removal of neurostimulator electrode array, sacral, with integrated neurostimulator | Policies naming 0787T |
| 63185 | On the list | Laminectomy with rhizotomy; more than 2 segments | Policies naming 63185 |
| 63190 | On the list | Laminectomy, with release of tethered spinal cord, lumbar | Policies naming 63190 |
| 63655 | On the list | Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural | Policies naming 63655 |
| 64561 | On the list | Percutaneous implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) | Policies naming 64561 |
| 64581 | On the list | Open implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) | Policies naming 64581 |
| 64585 | On the list | Revision or removal of peripheral neurostimulator electrode array [when specified as a sacral nerve stimulator] | Policies naming 64585 |
| 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 pulse generator or receiver [when specified as phrenic nerve stimulator for CG-MED-79] or [when specified as sacral nerve stimulator for CG-SURG-95] | Policies naming 64590 |
| 64595 | On the list | Revision or removal of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, with detachable connection to electrode array [when specified as sacral nerve stimulator] | Policies naming 64595 |
| C1767 | On the list | Generator, neurostimulator (implantable), nonrechargeable | Policies naming C1767 |
| C1820 | On the list | Generator, neurostimulator (implantable), with rechargeable battery and charging system | Policies naming C1820 |
| C1883 | On the list | Adapter/extension, pacing lead or neurostimulator lead (implantable) | Policies naming C1883 |
| L8679 | On the list | Neurostimulator Implantation - Implantable neurostimulator, pulse generator, any type | Policies naming L8679 |
| L8680 | On the list | Neurostimulator Implantation - Implantable heurostimulator electrode, each | Policies naming L8680 |
| L8682 | On the list | Implantable neurostimulator radiofrequency receiver | Policies naming L8682 |
| L8684 | Not listed | Policies naming L8684 | |
| 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 Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list