Anthem Blue Cross Blue Shield of California policy
SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain is a public Anthem Blue Cross Blue Shield of California policy (policy SURG.00158). It lists 16 CPT or HCPCS codes, 16 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.00158
- 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 |
|---|---|---|---|
| 64555 | On the list | Percutaneous implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve) | Policies naming 64555 |
| 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 |
| 64596 | On the list | Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; initial electrode array | Policies naming 64596 |
| 64597 | On the list | Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; each additional electrode array (List separately in addition to code for primary procedure) | Policies naming 64597 |
| A4438 | On the list | Adhesive clip applied to the skin to secure external electrical nerve stimulator controller, each | Policies naming A4438 |
| C1767 | On the list | Generator, neurostimulator (implantable), nonrechargeable | Policies naming C1767 |
| C1778 | On the list | Lead, neurostimulator (implantable) | Policies naming C1778 |
| C1787 | On the list | Patient programmer, neurostimulator | Policies naming C1787 |
| C9807 | On the list | Nerve stimulator, percutaneous, peripheral (e.g., Sprint peripheral nerve stimulation system), including electrode and all disposable system components, non-opioid medical device | Policies naming C9807 |
| L8678 | On the list | Electrical stimulator supplies (external) for use with implantable neurostimulator, per month | Policies naming L8678 |
| 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 |
| L8681 | On the list | Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only | Policies naming L8681 |
| L8683 | On the list | Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver | Policies naming L8683 |
| L8688 | On the list | Implantable neurostimulator pulse generator, dual array, non- rechargeable, includes extension | Policies naming L8688 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list