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Coverage criteria policies

Vagus Nerve Stimulation (VNS)

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for vagus nerve stimulation when the request is for a non-covered indication (see below).

Prior authorization is not required for vagus nerve stimulation when the request is for a covered indication (see below).

Coverage

Vagus Nerve Stimulation is covered subject to the indications listed below and per your plan documents.

Indications that are covered

Implantable Vagus Nerve Stimulation is a covered service for patients aged 4 or greater when:

  1. The patient has a clinical diagnosis of partial onset or generalized seizures, and
  2. The seizures have not been responsive or the patient is intolerant to the appropriate levels of at least 2 anti-epileptic medications, and
  3. The patient is functionally impaired due to the frequency or intensity of seizure activity, and
  4. Surgery is not a recommended option for the patient (e.g. the patient has been evaluated for intracranial surgical procedures for epilepsy by an epilepsy surgery program) or the patient cannot tolerate a pre-surgical evaluation.

Indications that are not covered

Vagus nerve stimulation is not covered for any additional indications, including, but not limited to:

  1. Morbid obesity
  2. Depression
  3. Alzheimer’s disease

Definitions

Implantable vagus nerve stimulators (VNS) generate an electrical impulse, which activates the vagus nerve and decreases the frequency of seizures in selected patients. The mechanism of action of this device has not been defined.

The device is similar in design to a cardiac pacemaker. It is implanted under the skin in a patient's chest. An electrode connects the generator (battery) to the patient's vagus nerve in the lower neck region. The stimulation of the nerve transmits the electrical impulse to the brain.

The NeuroCybernetic Prosthesis® (NCP®) System is an example of a Food and Drug Administration (FDA) approved implantable vagus nerve stimulation treatment device.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

ICD-10-CM Codes

Codes

Description

G40.001-G40.019

Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable

G40.101-G40.119

Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures

G40.201-G40.219

Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures

G40.311-G40.319

Generalized idiopathic epilepsy and epileptic syndromes

G40.411-G40.419

Other generalized epilepsy and epileptic syndromes

G40.803

Other epilepsy, intractable, with status epilepticus

G40.804

Other epilepsy, intractable, without status epilepticus

G40.811

Lennox-Gastaut syndrome, not intractable, with status epilepticus

G40.813

Lennox-Gastaut syndrome, intractable, with status epilepticus

G40.814

Lennox-Gastaut syndrome, intractable, without status epilepticus

G40.823

Epileptic spasms, intractable, with status epilepticus

G40.824

Epileptic spasms, intractable, without status epilepticus

G40.89

Other seizures

G40.911-G40.919

Epilepsy, unspecified, intractable

G40.A11-G40.A19

Absence epileptic syndrome, intractable

G40.B11-G40.B19

Juvenile myoclonic epilepsy, intractable

CPT codes

Codes

Description

61885

Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array

61886

Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays

61888

Revision or removal of cranial neurostimulator pulse generator or receiver

64553

Percutaneous implantation of neurostimulator electrode array; cranial nerve

64568

Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator

64569

Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References
  1. Schachter, S. Vagus nerve stimulation therapy for the treatment of epilepsy. In: Up to Date, Pedley, T (Ed) UpToDate, Waltham, MA. (Accessed on 7/5/2017.)
  2. Hayes, Inc. Hayes Directory. Vagus Nerve Stimulation for Depression. Lansdale, PA: Hayes, Inc.; 10/ 2013. Update 8/2016. Reviewed 7/2017.
  3. Hayes, Inc. Hayes Directory. Vagus Nerve Stimulation for Epilepsy. Lansdale, PA: Hayes, Inc.;6/2014. 5/2016; 5/2017. Reviewed 7/2017.
  4. Lim, R. Bariatric procedures for the management of severe obesity: Descriptions In: Up to Date. Jones, D. (Ed). Up to Date, Waltham, MA (accessed 8/29/2017)

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Policy activity

  • 07/01/1998 - Date of origin
  • 05/01/2012 - Effective date
Review date
  • 08/2017

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