Anthem Blue Cross Blue Shield of California 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 Blue Shield of California policy (policy SURG.00112). It lists 18 CPT or HCPCS codes, 18 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
- 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 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 |
|---|---|---|---|
| 1057T | On the list | Insertion or replacement of subcutaneous neurostimulator pulse generators, with tunneling of 4 electrode arrays, bilateral supraorbital and occipital nerves, including all interrogation, programming, and imaging guidance, when performed | Policies naming 1057T |
| 1058T | On the list | Revision of implanted subcutaneous unilateral supraorbital and occipital neurostimulator system, including all interrogation, programming, and imaging guidance, when performed | Policies naming 1058T |
| 1059T | On the list | Removal of implanted subcutaneous unilateral supraorbital and occipital neurostimulator system | Policies naming 1059T |
| 1060T | On the list | Electronic analysis of implanted subcutaneous supraorbital- occipital neurostimulator pulse generator (eg, frequency, amplitude, pulse width, leads, electrode configuration); with complex programming by physician or other qualified health care professional | Policies naming 1060T |
| 1061T | On the list | Electronic analysis of implanted subcutaneous supraorbital- occipital neurostimulator pulse generator (eg, frequency, amplitude, pulse width, leads, electrode configuration); with simple programming by physician or other qualified health care professional | Policies naming 1061T |
| 61885 | On the list | Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array | Policies naming 61885 |
| 64553 | On the list | Percutaneous implantation of neurostimulator electrodes; cranial nerve | Policies naming 64553 |
| 64555 | On the list | Percutaneous implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve) | Policies naming 64555 |
| 64568 | On the list | Open implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator | Policies naming 64568 |
| 64569 | On the list | Revision or replacement of cranial nerve (e.g., vagus nerve) neurostimulator electrode array, including connection to existing pulse generator | Policies naming 64569 |
| 64575 | On the list | Open implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve) [when specified as phrenic nerve stimulator for CG-MED-79] | 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 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 |
| 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 | Neurostimulator Implantation - Implantable neurostimulator, pulse generator, any type | Policies naming L8679 |
| L8680 | On the list | Neurostimulator Implantation - Implantable heurostimulator 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 Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list