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.