Harvard Pilgrim Health Care Home
  Learn more.
  Sign up for HPHConnect.
Medical Management
For Your Patient
News Center
Network Matters
Newsletter Archives
Newsletter Registration
Office Support
Provider Manual
Medicare Advantage
Research & Teaching
Resources & Links
Print    Text Size

Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

April 2018

Updates to Implantable Neurostimulators Medical Review Criteria

Harvard Pilgrim covers the use of implantable neurostimulators for certain conditions with prior authorization, and is updating our commercial medical review criteria, effective for dates of service beginning April 26, 2018.

The changes include adding additional criteria that must be met for the coverage of sacral nerve stimulators for urinary incontinence and for fecal incontinence, and excluding numerous conditions from coverage for spinal nerve stimulation and vagus stimulation.

In addition, the following CPT codes are being removed from the policy, and will no longer be covered:

  • 64555 – Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
  • 64575 – Incision for implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
  • 64585 – Revision or removal of peripheral neurostimulator electrode array

For more detailed information, please refer to Harvard Pilgrim’s updated commercial Implantable Neurostimulators Medical Review Criteria. To request prior authorization, please complete the Implantable Neurostimulators Prior Authorization Request Form and fax it to 800-232-0816.

    Email this article to a colleague   

    Network Matters Archives

    Download printer-friendly version


    Reminder: Medical Drugs & Buy-and-Bill or Specialty Pharmacy


    Cochlear Implants to Require Prior Authorization

    Update to Bariatric Surgeries Prior Authorization Policy

    New Bunionectomy Medical Review Criteria

    Harvard Pilgrim Adding Coverage for Newly Approved Medications

    Tips for Efficient Pharmacy Prior Authorization Process

    Complex Case Management Services

    Disease Management Programs Reinforce Physician Treatment Plans

    Updates to Medical Policies and Prior Authorization Criteria

    Policy Update: Replacement of the First Metatarsophalangeal Joint

    Updates to Implantable Neurostimulators Medical Review Criteria

    Corneal Collagen Cross-Linking Now Covered

    New Prior Authorization Policy for Hemlibra

    New Prior Authorization Policy for Imfinzi

    Substance Use Disorder: Treatment and Helpful Resources

    P&T Committee Meeting Update


    Payment Policy Updates: DME and Orthotic and Prosthetic Devices

    Medical Records: Common Issues and Quick Fixes


    Eric H. Schultz,
    President and Chief Executive Officer

    Robert Farias,
    Senior Vice President, Corporate Network Strategy

    Annmarie Dadoly,

    Joseph O'Riordan,

    Kristin Edmonston,
    Production Coordinator