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Vagus Nerve Stimulation

Policy Number: MP-260

Latest Review Date: February 2024

Category: Surgery                                                    

POLICY:

Vagus Nerve Stimulation (VNS) may be considered medically necessary as a treatment of medically refractory seizures.

Vagus Nerve Stimulation (VNS) is considered investigational as a treatment of all other conditions including but not limited to: 

  • Alzheimer’s disease
  • Chronic heart failure
  • Depression
  • Essential tremor
  • Fibromyalgia
  • Headaches
  • Obesity
  • Tinnitus
  • Traumatic brain injury.
  • Upper-limb impairment due to stroke

 

Transcutaneous (non-implantable) vagus nerve stimulation devices are considered investigational for all indications.

POLICY GUIDELINES:

Medically refractory seizures are defined as seizures that occur despite therapeutic levels of antiepileptic drugs or seizures that cannot be treated with therapeutic levels of antiepileptic drugs because of intolerable adverse events of these drugs.

Vagus nerve stimulation has been evaluated for the treatment of obesity. This indication is addressed in Medical Policy# 598- Vagus Nerve Blocking Therapy for Treatment of Obesity.

DESCRIPTION OF PROCEDURE OR SERVICE:

Stimulation of the vagus nerve can be performed by means of a pulsed electrical stimulator implanted within the carotid artery sheath. This technique has been proposed as a treatment for refractory seizures, depression, and other disorders. There are also devices available that are implanted at different areas of the vagus nerve. This policy also addresses devices that stimulate the vagus nerve transcutaneously.

Vagus Nerve Stimulation

Vagus nerve stimulation (VNS) was initially investigated as a treatment alternative in patients with medically refractory partial-onset seizures for whom surgery is not recommended or for whom surgery has failed. Over time, the use of VNS has expanded to generalized seizures, and it has been investigated for a range of other conditions.

While the mechanisms for the therapeutic effects of VNS are not fully understood, the basic premise of VNS in the treatment of various conditions is that vagal visceral afferents have a diffuse central nervous system projection, and activation of these pathways has a widespread effect on neuronal excitability. An electrical stimulus is applied to axons of the vagus nerve, which have their cell bodies in the nodose and junctional ganglia and synapse on the nucleus of the solitary tract in the brainstem. From the solitary tract nucleus, vagal afferent pathways project to multiple areas of the brain. VNS may also stimulate vagal efferent pathways that innervate the heart, vocal cords, and other laryngeal and pharyngeal muscles, and provide parasympathetic innervation to the gastrointestinal tract.

 

Other types of implantable vagus nerve stimulators that are placed in contact with the trunks of the vagus nerve at the gastroesophageal junction are not addressed in this evidence review.

KEY POINTS:

This evidence review has been updated regularly with searches of the PubMed database. The most recent literature update was performed through December 21, 2023.

Summary of Evidence

Implantable Vagus Nerve Stimulation

For individuals who have seizures refractory to medical treatment who receive vagus nerve stimulation (VNS), the evidence includes randomized controlled trials (RCTs) and multiple observational studies. Relevant outcomes are symptoms, change in disease status, and functional outcomes. The RCTs have reported a significant reduction in seizure frequency for patients with partial-onset seizures. The uncontrolled studies have consistently reported large reductions for a broader range of seizure types in both adults and children. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have treatment-resistant depression who receive VNS, the evidence includes 2 RCTs evaluating the efficacy of implanted VNS for treatment-resistant depression compared to sham, 1 RCT comparing therapeutic to low-dose implanted VNS, non-randomized comparative studies, and case series. Relevant outcomes are symptoms, change in disease status, and functional outcomes. The sham-controlled RCTs only reported short-term results and found no significant improvement in the primary outcome. The low-dose VNS controlled trial reported no statistically significant differences between the dose groups for change in depression symptom score from baseline. Other available studies are limited by small sample sizes, potential selection and confounding biases, and lack of a control group in the case series. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have chronic heart failure who receive VNS, the evidence includes a systematic review including 4 RCTs and case series. Relevant outcomes are symptoms, change in disease status, and functional outcomes. Meta-analyses of the RCTs evaluating chronic heart failure found significant improvements in New York Heart Association functional class, quality of life, 6-minute walk-test, and N-terminal-pro brain natriuretic peptide levels in patients treated with VNS compared to control. An analysis of the ANTHEM-HF uncontrolled trial evaluated longer-term outcomes of VNS use in chronic heart failure. They found that left ventricular (LV) ejection fraction improved by 18.7%, 19.3%, and 34.4% at 12, 24, and 36 months, respectively, with high-intensity VNS. Individuals with low-intensity VNS only had significant improvement in LV ejection fraction at 24 months(12.3%). The ANTHEM-HFpEF trial found improvements in New York Heart Association functional class, quality of life, and 6-minute walk test distances in patients with preserved ejection fraction and implanted VNS. Although this data is promising, a lack of a no-VNS comparator group precludes drawing conclusions based on findings from the uncontrolled studies. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have upper-limb impairment due to stroke who receive VNS, the evidence includes 3 pilot RCTs and a systematic review of these RCTs. Relevant outcomes are symptoms, change in disease status, and functional outcomes. Two RCTs compared VNS plus rehabilitation to rehabilitation alone; 1 failed to show significant improvements for the VNS group on response and function outcomes, but the other, which had a larger patient population, found a significant difference in response and function outcomes. The other RCT compared VNS to sham and found that although VNS significantly improved response rate, there were 3 serious adverse events related to surgery. A systematic review pooling these data found that implanted VNS improved upper limb motor function based on Fugl-Meyer Assessment-Upper Extremity score when compared to control. Longer-term follow-up studies are needed to evaluate long-term efficacy and safety. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have other neurologic conditions (e.g., essential tremor, headache, fibromyalgia, tinnitus, autism) who receive VNS, the evidence includes case series. Relevant outcomes are symptoms, change in disease status, and functional outcomes. Case series are insufficient to draw conclusions regarding efficacy. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Transcutaneous Vagus Nerve Stimulation

For individuals with cluster headaches who receive transcutaneous VNS (tVNS; also referred to as noninvasive VNS [nVNS]) to prevent cluster headaches, the evidence includes one RCT. Relevant outcomes are symptoms, change in disease status, quality of life and functional outcomes. One RCT for prevention of cluster headache showed a reduction in headache frequency but did not include a sham treatment group. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with cluster headache who receive noninvasive transcutaneous VNS (nVNS) to treat acute cluster headache, the evidence includes RCTs. Relevant outcomes are symptoms, change in disease status, quality of life and functional outcomes. (ACT1) and (ACT2) RCTs compared nVNS to sham for treatment of acute cluster headache in patients including both chronic and episodic cluster headache. In ACT1, there was no statistically significant difference in the overall population in the proportion of patients with pain score of 0 or 1 at 15 minutes into the first attack and no difference in the proportion of patients who were pain-free at 15 minutes in 50% or more of the attacks. In the episodic cluster headache subgroup (n=85) both outcomes were statistically significant favoring nVNS although the interaction p-value was not reported. In ACT2, the proportion of attacks with pain intensity score of 0 or 1 at 30 minutes was higher for nVNS in the overall population (43% vs. 28%, p=0.05) while the proportion of attacks that were pain-free at 15 minutes was similar in the 2 treatment groups in the overall population (14% vs. 12%). However, a statistically significantly higher proportion of attacks in the episodic subgroup (n=27) were pain-free at 15 minutes in the nNVS group compared to sham (48% vs. 6%, p<0.01). These studies suggest that people with episodic and chronic cluster headaches may respond differently to acute treatment with nVNS. Studies designed to focus on episodic cluster headache are needed. The measurements of quality of life and functional outcomes have not been reported. Treatment periods ranged from only 2 weeks to 1 month with extended open-label follow-up of up to 3 months. There are few adverse events of nVNS and they are mild and transient. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with migraine headache who receive nVNS to treat acute migraine headache, the evidence includes 1 RCT. Relevant outcomes are symptoms, change in disease status, quality of life and functional outcomes. One RCT has evaluated nNVS for acute treatment of migraine with nVNS in 248 patients with episodic migraine with/without aura. There was not a statistically significant difference in the primary outcome of the proportion of participants who were pain-free without using rescue medication at 120 minutes (30% vs. 20%; p = 0.07). However, the nVNS group had a higher proportion of patients with decrease in pain from moderate or severe to mild or no pain at 120 minutes (41% vs. 28%; p=0.03) and a higher proportion of patients who were pain-free at 120 minutes for 50% or more of their attacks (32% vs. 18%; p=0.02). There are few adverse events of nVNS and they are mild and transient. The measurements of quality of life and functional outcomes were not reported and the double-blind treatment period was 4 weeks with an additional four weeks of open-label treatment. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with chronic migraine headache who receive nVNS to prevent migraine headache, the evidence includes two RCTs. The relevant outcomes are symptoms, change in disease status, quality of life and functional outcomes. The (EVENT) RCT was a feasibility study of prevention of migraine that was not powered to detect differences in efficacy outcomes. It does not demonstrate the efficacy of nVNS for prevention of migraine. The (PREMIUM) RCT was a phase 3, multicenter, sham-controlled RCT including 341 randomized participants with a 12-week double-blind treatment period. The results of PREMIUM demonstrated that nVNS was not statistically significantly superior to sham. with respect to the outcomes of reduction of at least 50% in migraine days from baseline to the last 4 weeks, reduction in number of migraine days from baseline to the last 4 weeks or acute medication days. The PREMIUM II trial was a multicenter, sham-controlled RCT including 231 randomized participants with a 12-week double-blind treatment period. The trial was terminated early due to the COVID-19 pandemic and results were based on a modified intention to treat population that included 113 total participants. Results demonstrated that treatment with nVNS was not statistically significantly superior to sham with respect to the primary outcome of reduction in the number of migraine days per month during weeks 9 through 12, nor other outcomes such as mean change in the number of headache days or acute medication days. However, the percentage of patients with at least a 50% reduction in the number of migraine days was significantly greater in the nVNS group than in the sham group. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have other neurologic, psychiatric, or metabolic disorders (e.g., epilepsy, depression, schizophrenia, noncluster headache, impaired glucose tolerance) who receive tVNS, the evidence includes RCTs, systematic reviews of these RCTs, and case series for some of the conditions. Relevant outcomes are symptoms, change in disease status, and functional outcomes. The RCTs are all small and have various methodologic problems. None showed definitive efficacy of tVNS in improving patient outcomes. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Practice Guidelines and Position Statements

American Academy of Neurology

In 1999, the American Academy of Neurology released a consensus statement on the use of vagus nerve stimulation (VNS) in adults, which stated: “VNS is indicated for adults and adolescents over 12 years of age with medically intractable partial seizures who are not candidates for potentially curative surgical resections, such as lesionectomies or mesial temporal lobectomies. The guidelines were updated in 2013 and reaffirmed in 2022, stating: “VNS may be considered for seizures in children, for LGS [Lennox-Gastaut syndrome]-associated seizures, and for improving mood in adults with epilepsy (Level C). VNS may be considered to have improved efficacy over time (Level C).

American Psychiatric Association

Updated in 2010, the American Psychiatric Association guidelines on the treatment of major depressive disorder in adults, includes the following statement on the use of VNS: “Vagus nerve stimulation (VNS) may be an additional option for individuals who have not responded to at least four adequate trials of antidepressant treatment, including ECT [Electroconvulsive therapy],” with a level of evidence III (May be recommended on the basis of individual circumstances)."

National Institute for Health and Care Excellence

In 2016, the NICE issued guidance on use of transcutaneous stimulation of the cervical branch of the vagus nerve for cluster headache and migraine(IPG552). The guidance states: “Current evidence on the safety of transcutaneous stimulation of the cervical branch of the vagus nerve for cluster headache and migraine raises no major concerns. The evidence on efficacy is limited in quantity and quality.” The guidance also comments that further research is needed to clarify whether the procedure is used for treatment or prevention, for cluster headache or migraine, appropriate patient selection, and treatment regimen and suggests that outcome measures should include changes in the number and severity of cluster headache or migraine episodes, medication use, quality of life in the short and long term, side effects, acceptability, and device durability.

In 2018, the NICE also published a Medtech innovation briefing on noninvasive VNS for cluster headache (MIB162). The briefing states that the "intended place in therapy would be as well as standard care, most likely where standard treatments for cluster headache are ineffective, not tolerated or contraindicated" and that key uncertainties around the evidence are that 'people with episodic and chronic cluster headaches respond differently to treatment with gammaCore. The optimal use of gammaCore in the different populations is unclear. The NICE published a Medical technologies guidance [MTG46] on gammaCore for cluster headache in December 2019. The recommendations state that evidence supports using gammaCore to treat cluster headache and that gammaCore is not effective in everyone with cluster headache.

In 2020, the NICE published an Interventional Procedure Overview on implanted vagus nerve stimulation for treatment-resistant depression (IPG679). The guidance states: "Evidence on the safety of implanted vagus nerve stimulation for treatment-resistant depression raises no major safety concerns, but there are frequent, well-recognized side effects. Evidence on its efficacy is limited in quality. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research." The guidance further states that "NICE encourages further research into implanted vagus nerve stimulation for treatment-resistant depression, in the form of randomized controlled trials with a placebo or sham stimulation arm. Studies should report details of patient selection. Outcomes should include validated depression rating scales, patient-reported quality of life, time to onset of effect and duration of effect, and any changes in concurrent treatment."

U.S. Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Vagus nerve stimulation (VNS), partial-onset seizures, depression, headaches, essential tremor, Alzheimer’s disease, VNS (t-VNS®), VNS (gammaCore®) Non-implantable Vagus Nerve stimulation, Maestro® System, transcutaneous vagus nerve stimulation, AspireSR®, NeuroCybernetic Prosthesis (NCP®), Sapphire D, GammaCore Sapphire CV, nVNS

APPROVED BY GOVERNING BODIES:

Table 1. FDA-Approved or -Cleared Vagus Nerve Stimulators

Device Name

Manufacturer

Approved/Cleared

PMA/510(k)

Product Code(s)

Indications

 

NeuroCybernetic Prosthesis (NCP®)/VNS Therapy

LivaNova(Cyberonics)

1997

P970003

 LYJ, MUZ

Indicated or adjunctive treatment of adults and adolescents >12 y of age with medically refractory partial-onset seizures

 

 

 

2005

P970003/S50

 

Expanded indication for adjunctive long-term treatment of chronic or recurrent depression for patients ≥18 y of age experiencing a major depressive episode and have not had an adequate response to ≥4 adequate antidepressant treatments

 

 

 

2017

P970003/S207

 

Expanded indicated use as adjunctive therapy for seizures in patients ≥4 y of age with partial-onset seizures that are refractory to antiepileptic medications

 

gammaCore®

ElectroCore

2017/2018

DEN150048/K171306/K173442

PKR, QAK

Indicated for acute treatment of pain associated with episodic cluster and migraine headache in adults using noninvasive VNS on the side of the neck

 

gammaCore-2®,GammaCore-Sapphire®

ElectroCore

2017/2018/2021

K172270/K180538/K182369/K191830

K203456/K211856

PKR

Indicated for:

Adjunctive use for the preventive treatment of cluster headache in adult patients.

The acute treatment of pain associated with episodic cluster headache in adult patients.

The acute treatment of pain associated with migraine headache in adult patients. The preventive treatment of migraine headache in adult patients.

 

FDA: Food and Drug Administration; PMA: premarket approval; VNS: vagus nerve stimulation.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP: Special benefit consideration may apply.  Refer to member’s benefit plan.

CURRENT CODING: 

CPT Codes:   

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 two or more electrode arrays  

64553

Percutaneous implantation of neurostimulator electrodes array; cranial nerve

64568

Open implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator

64569

Revision or replacement of cranial nerve (e.g., Vagus nerve) neurostimulator electrode array.  Including connection to pulse generator

64570

Removal of cranial nerve (e.g., vagus nerve) Neurostimulator electrode array and pulse generator

95976

Electronic analysis of implanted neurostimulator pulse generator/transmitter (e.g., contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple cranial nerve neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional (Effective 01/01/2019)

95977

Electronic analysis of implanted neurostimulator pulse generator/transmitter (e.g., contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex cranial nerve neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional (Effective 01/01/2019)

HCPCS:

E0735

Non-invasive vagus nerve stimulator (Effective 01/01/24)

L8680

Implantable neurostimulator electrode (with any number of contact points), each

L8681

Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only

L8682

Implantable neurostimulator radiofrequency receiver

L8683

Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver

L8684

Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement

L8685

Implantable neurostimulator pulse generator, single array, rechargeable, includes extension

L8686

Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension

L8687

Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension

L8688

Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension

L8689

External recharging system for battery (internal) for use with implantable neurostimulator, replacement only

PREVIOUS CODING:

K1020

Non-invasive vagus nerve stimulator (Deleted 12/31/23)

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  51. Nearing BD, Libbus I, Carlson GM, et al. Chronic vagus nerve stimulation is associated with multi-year improvement in intrinsic heart rate recovery and left ventricular ejection fraction in ANTHEM-HF. Clin Auton Res. Jun 2021; 31(3): 453-462.
  52. Panebianco M, Rigby A, Marson AG. Vagus nerve stimulation for focal seizures. Cochrane Database Syst Rev. Jul 14 2022; 7(7): CD002896. 
  53. Panebianco M, Rigby A, Weston J, et al. Vagus nerve stimulation for partial seizures. Cochrane Database Syst Rev. Apr 03 2015; (4):Cd002896.
  54. Premchand RK, Sharma K, Mittal S, et al. autonomic regulation therapy via left or right cervical vagus nerve stimulation in patients with chronic heart failure: results of the ANTHEM-HF trial. J Card Fail. Nov 2014; 20(11):808-816.
  55. Ramos-Castaneda JA, Barreto-Cortes CF, Losada-Floriano D, et al. Efficacy and Safety of Vagus Nerve Stimulation on Upper Limb Motor Recovery After Stroke. A Systematic Review and Meta-Analysis. Front Neurol. 2022; 13: 889953.
  56. Rong P, Liu A, Zhang J, et al. Transcutaneous vagus nerve stimulation for refractory epilepsy: a randomized controlled trial. Clin Sci (Lond). Apr 01 2014.
  57. Ryvlin P, Gilliam FG, Nguyen DK, et al. The long-term effect of vagus nerve stimulation on quality of life in patients with pharmaco-resistant focal epilepsy: the PuLsE (Open Prospective Randomized Long-term Effectiveness) trial. Epilepsia. Jun 2014; 55(6):893-900.
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POLICY HISTORY:

Medical Policy Group, March 2006 (3)

Medical Policy Administration Committee, March 2006

Available for comment March 14-April 27, 2006

Medical Policy Group, September 2006 (1)

Medical Policy Group, October 2007 (1)

Medical Policy Group, March 2009 (4)

Medical Policy Group, March 2010 (3)

Medical Policy Administration Committee, April 2010

Available for comment April 8-May 23, 2010

Medical Policy Group, December 2010 – code updates

Medical Policy Group, March 2011 (3): Description, Policy, Key Points, References updated

Medical Policy Group, December 2011 (3): 2012 Code Updates – verbiage change to codes 64553. 95974 & 95975

Medical Policy Group, March 2012 (3): 2012 Update – Key Points & References

Medical Policy Panel, March 2013

Medical Policy Group, April 2013 (3): 2013 Updates to Key Points; no change in policy statement

Medical Policy Panel March 2014

Medical Policy Group March 2014 (4):  Updated Description, updated policy section by adding that VNS for tinnitus and traumatic brain injury also added non-implantable vagus nerve stimulation devices are investigational.  Reworked Key Points Updated Key Words and References.

Available for comment May 2 through July 5, 2014

Medical Policy Group, May 2014 (5):  2014 Coding Update:  Deleted code L8680 effective July 1, 2014.

Medical Policy Group, June 2014 (5): Quarterly 2014 Coding Update:  Code L8680 did not delete; Removed delete date and moved code up under active codes.

Medical Policy Panel, March 2015

Medical Policy Group, March 2015 (6):  Updates to Description, Key Points, Key Words, Codes and References; no change to policy statement.

Medical Policy Panel, February 2016

Medical Policy Group, February 2016 (6):  Updates to Description, Key Points, Approved by Governing Bodies and References; no changes to policy statement.

Medical Policy Panel, October 2017

Medical Policy Group, October 2017 (6): Updates to Description, Key Points, Governing Bodies, Practice Guidelines and References. Added “upper-limb impairment due to stroke” to policy statement.

Medical Policy Panel March 2018

Medical Policy Group, April 2018 (6) Updates to Description, Key Points, Key Words, Governing Bodies and References.

Medical Policy Group, December 2018:  2019 Annual Coding Update.  Added CPT codes 95976 and 95977 to the Current coding section. Moved CPT codes from Current coding section to previous coding. Created previous coding section to include codes 95974 and 95975.

Medical Policy Panel, February 2019

Medical Policy group, March 2019 (3): 2019 Updates to Description, Key Points, Practice Guidelines and Position Statements, and References. No changes to policy statement or intent.

Medical Policy Panel, February 2020

Medical Policy Group, March 2020 (3): 2020 Updates to Key Points, Practice Guidelines and Position Statements, and References. No changes to policy statement or intent.

Medical Policy Group, March 2021: Quarterly Coding Update.  Added new code K1020 to Current Coding. Added Key Word Sapphire D.

Medical Policy Panel, February 2021

Medical Policy Group, March 2021 (3): 2021 Updates to Key Points, Practice Guidelines and Position Statements, and References. Added Policy Guidelines section. Policy statement updated to remove “not medically necessary,” no other changes to policy statement or intent.

Medical Policy Group, April 2021 (3): Additional 2021 Update to add new Noninvasive Vagus Nerve Stimulator. Added GammaCore CV and nVNS to Key Words. Updated Approved by Governing Bodies due to the emergency use authorization by the FDA for use in an acute setting or at home during Covid-19 pandemic. Added one reference. No changes to policy statement or intent.

Medical Policy Group, December 2021: 2022 Annual Coding Update.  Revised CPT code 64568 changes: “Open” added to descriptor and “incision for” removed.

Medical Policy Panel, February 2022

Medical Policy Group, February 2022 (3): 2022 Updates to Key Points, Practice Guidelines and Position Statements, Approved by Governing Bodies, and References. No changes to policy statement or intent.

Medical Policy Panel, February 2023

Medical Policy Group, March 2023 (3): 2023 Updates to Key Points, Practice Guidelines and Position Statements, Approved by Governing Bodies, Benefit Applications, and References. No changes to policy statement or intent.

Medical Policy Group, December 2023: 2024 Annual HCPCS Coding Update: Added E0735, K1020 deleted.

Medical Policy Panel, February 2024

Medical Policy Group, February 2024 (3): Updates to Description, Key Points, Governing Bodies, Practice Guidelines and References.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.