Stride Medical Policy Update: Implantable Neurostimulators

Harvard Pilgrim is updating our StrideSM(HMO) Medicare Advantage Implantable Neurostimulators Medical Policy, effective for dates of service beginning Oct. 1, 2020. Updates to the policy include, but are not limited to:

  • Adding coverage criteria per Original Medicare’s National Coverage Determination (NCD) for:
    • unilateral or bilateral thalamic ventralis intermedius nucleus (VIM) deep brain stimulators (DBS) for the treatment of essential tremor and/or Parkinsonian tremor per NCD
    • unilateral or bilateral subthalamic nucleus (STN) or globus pallidus interna (GPi) DBS for the treatment of Parkinson’s disease
  • Adding criteria for sacral nerve stimulator for fecal incontinence to align with the commercial policy
  • Adding a number of items to the list of coverage exclusions

In addition, Harvard Pilgrim will require prior authorization for the following CPT codes for members of our Medicare Advantage plans:

  • 63663 –Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed
  • 64568 –Incision for implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator
  • 95980 –Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric neurostimulator pulse generator/transmitter; intraoperative, with programming
  • 95981 –Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric neurostimulator pulse generator/transmitter; subsequent, without reprogramming
  • 95982 –Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric neurostimulator pulse generator/transmitter; subsequent, with reprogramming

For complete information, please refer to Harvard Pilgrim’s updated StrideSM(HMO) Medicare Advantage Implantable Neurostimulators Medical Policy. 


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