Aetna Vagus Nerve Stimulation coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• Vagus nerve electrical stimulators are medically necessary durable medical equipment (DME) for shortening the duration or reducing the severity of seizures in members with focal seizures (formerly known as partial onset seizures) who meet ALL of: (a) remain refractory to optimal anti-epileptic medications and/or surgical intervention (such as a lesionectomy or medial temporal lobectomy), OR have debilitating side effects from anti-epileptic medications; AND (b) have NO history of a bilateral or left cervical vagotomy
• Vagus nerve electrical stimulators are medically necessary durable medical equipment (DME) for the treatment of Lennox-Gastaut syndrome in members who meet ALL of: (a) remain refractory to optimal anti-epileptic medications, and/or surgical intervention (such as a corpus callosotomy or lesional epilepsy surgery), OR have debilitating side effects from anti-epileptic medications; AND (b) have NO history of a bilateral or left cervical vagotomy
• Replacement/revision of a vagus nerve therapy system/handheld magnet is medically necessary if ALL of: the original system/magnet met criteria as medically necessary AND is no longer under warranty AND cannot be repaired
• Electronic analysis of an implanted neurostimulator pulse generator system for vagus nerve stimulation is medically necessary when criteria are met

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 61885·PA verdict·Rate
• 64553·PA verdict·Rate
• 64568·PA verdict·Rate
• 64569·PA verdict·Rate
• 64570·PA verdict·Rate
• 95970·PA verdict·Rate
• 95976·PA verdict·Rate

Frequently asked questions

When does Aetna cover Vagus Nerve Stimulation (CPT 61885), and what gets it denied?

Aetna CPB 0191 covers implanted vagus nerve stimulators as medically necessary DME for drug-refractory focal (partial onset) seizures and for Lennox-Gastaut syndrome, but only in members who are refractory to optimal anti-epileptic medications and/or epilepsy surgery (or who have debilitating medication side effects) AND who have no history of bilateral or left cervical vagotomy; replacement/revision and electronic analysis of the pulse generator are also covered when criteria are met. Transcutaneous VNS and VNS for essentially all other indications (e.g., depression, migraine, obesity, rheumatoid arthritis, Alzheimer's, and many more) are considered experimental, investigational, or unproven. The bulletin is silent on precertification/prior authorization. Coverage criteria include: Vagus nerve electrical stimulators are medically necessary durable medical equipment (DME) for shortening the duration or reducing the severity of seizures in members with focal seizures (formerly known as partial onset seizures) who meet ALL of: (a) remain refractory to optimal anti-epileptic medications and/or surgical intervention (such as a lesionectomy or medial temporal lobectomy), OR have debilitating side effects from anti-epileptic medications; AND (b) have NO history of a bilateral or left cervical vagotomy; Vagus nerve electrical stimulators are medically necessary durable medical equipment (DME) for the treatment of Lennox-Gastaut syndrome in members who meet ALL of: (a) remain refractory to optimal anti-epileptic medications, and/or surgical intervention (such as a corpus callosotomy or lesional epilepsy surgery), OR have debilitating side effects from anti-epileptic medications; AND (b) have NO history of a bilateral or left cervical vagotomy; Replacement/revision of a vagus nerve therapy system/handheld magnet is medically necessary if ALL of: the original system/magnet met criteria as medically necessary AND is no longer under warranty AND cannot be repaired; Electronic analysis of an implanted neurostimulator pulse generator system for vagus nerve stimulation is medically necessary when criteria are met. Applies to 7 codes: 61885, 64553, 64568, 64569, 64570, 95970, 95976. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: Contraindication / non-coverage: members with a history of a bilateral or left cervical vagotomy are excluded from medically necessary vagus nerve stimulation (the medical-necessity criteria require NO history of bilateral or left cervical vagotomy); Experimental, investigational, or unproven: Integrated vagus nerve stimulator (e.g., SetPoint System) for multiple sclerosis, psoriatic arthritis, and rheumatoid arthritis; Experimental, investigational, or unproven: Transcutaneous vagus nerve stimulation (e.g., Stivax device) for post-laminectomy syndrome, seizures, and all other indications; Experimental, investigational, or unproven: VNS and transcutaneous VNS for chronic migraine attack prevention; Experimental, investigational, or unproven: VNS and transcutaneous VNS for prevention/attenuation of myocardial ischemia-reperfusion injury; Experimental, investigational, or unproven (not an all-inclusive list): VNS and transcutaneous VNS for addictions; Experimental, investigational, or unproven: VNS and transcutaneous VNS for Alzheimer disease; Experimental, investigational, or unproven: VNS and transcutaneous VNS for anxiety disorders; Experimental, investigational, or unproven: VNS and transcutaneous VNS for atonic seizures; Experimental, investigational, or unproven: VNS and transcutaneous VNS for atrial fibrillation; Experimental, investigational, or unproven: VNS and transcutaneous VNS for autism; Experimental, investigational, or unproven: VNS and transcutaneous VNS for bipolar disorders; Experimental, investigational, or unproven: VNS and transcutaneous VNS for bulimia nervosa; Experimental, investigational, or unproven: VNS and transcutaneous VNS for cancer; Experimental, investigational, or unproven: VNS and transcutaneous VNS for cerebral palsy; Experimental, investigational, or unproven: VNS and transcutaneous VNS for Crohn's disease; Experimental, investigational, or unproven: VNS and transcutaneous VNS for chronic headaches; Experimental, investigational, or unproven: VNS and transcutaneous VNS for cluster headaches; Experimental, investigational, or unproven: VNS and transcutaneous VNS for cognitive impairment associated with Alzheimer's disease; Experimental, investigational, or unproven: VNS and transcutaneous VNS for coma; Experimental, investigational, or unproven: VNS and transcutaneous VNS for COVID-19; Experimental, investigational, or unproven: VNS and transcutaneous VNS for depression (including post-partum depression); Experimental, investigational, or unproven: VNS and transcutaneous VNS for Dravet syndrome; Experimental, investigational, or unproven: VNS and transcutaneous VNS for dysphagia; Experimental, investigational, or unproven: VNS and transcutaneous VNS for eating disorders (anorexia and bulimia); Experimental, investigational, or unproven: VNS and transcutaneous VNS for essential tremor; Experimental, investigational, or unproven: VNS and transcutaneous VNS for fibromyalgia; Experimental, investigational, or unproven: VNS and transcutaneous VNS for gastroparesis; Experimental, investigational, or unproven: VNS and transcutaneous VNS for generalized motor seizures (formerly generalized tonic-clonic seizures); Experimental, investigational, or unproven: VNS and transcutaneous VNS for generalized epilepsy syndromes; Experimental, investigational, or unproven: VNS and transcutaneous VNS for generalized treatment-resistant epilepsy; Experimental, investigational, or unproven: VNS and transcutaneous VNS for heart failure; Experimental, investigational, or unproven: VNS and transcutaneous VNS for hemicrania continua; Experimental, investigational, or unproven: VNS and transcutaneous VNS for impaired glucose tolerance/pre-diabetes; Experimental, investigational, or unproven: VNS and transcutaneous VNS for inflammation; Experimental, investigational, or unproven: VNS and transcutaneous VNS for intractable hiccups; Experimental, investigational, or unproven: VNS and transcutaneous VNS for juvenile myoclonic epilepsy; Experimental, investigational, or unproven: VNS and transcutaneous VNS for migraine headaches; Experimental, investigational, or unproven: VNS and transcutaneous VNS for mood disorders; Experimental, investigational, or unproven: VNS and transcutaneous VNS for narcolepsy; Experimental, investigational, or unproven: VNS and transcutaneous VNS for obesity; Experimental, investigational, or unproven: VNS and transcutaneous VNS for obsessive-compulsive disorder; Experimental, investigational, or unproven: VNS and transcutaneous VNS for panic disorder; Experimental, investigational, or unproven: VNS and transcutaneous VNS for post-traumatic stress disorder; Experimental, investigational, or unproven: VNS and transcutaneous VNS for Prader-Willi syndrome; Experimental, investigational, or unproven: VNS and transcutaneous VNS for rheumatoid arthritis; Experimental, investigational, or unproven: VNS and transcutaneous VNS for schizophrenia; Experimental, investigational, or unproven: VNS and transcutaneous VNS for Sjogren's syndrome; Experimental, investigational, or unproven: VNS and transcutaneous VNS for sleep disorder; Experimental, investigational, or unproven: VNS and transcutaneous VNS for status epilepticus; Experimental, investigational, or unproven: VNS and transcutaneous VNS for stroke; Experimental, investigational, or unproven: VNS and transcutaneous VNS for tinnitus; Experimental, investigational, or unproven: VNS and transcutaneous VNS for Tourette's syndrome; Experimental, investigational, or unproven: VNS and transcutaneous VNS for traumatic brain injury (TBI), including post-TBI pneumonia; Experimental, investigational, or unproven: VNS and transcutaneous VNS for vestibular migraine; Experimental, investigational, or unproven: VNS and transcutaneous VNS for all other indications not listed as medically necessary (list is not all-inclusive). Claims may be denied when the requested service falls under these.

Does Aetna require prior authorization for Vagus Nerve Stimulation?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.

What does Aetna exclude for Vagus Nerve Stimulation?

Policy exclusions and limitations: Contraindication / non-coverage: members with a history of a bilateral or left cervical vagotomy are excluded from medically necessary vagus nerve stimulation (the medical-necessity criteria require NO history of bilateral or left cervical vagotomy); Experimental, investigational, or unproven: Integrated vagus nerve stimulator (e.g., SetPoint System) for multiple sclerosis, psoriatic arthritis, and rheumatoid arthritis; Experimental, investigational, or unproven: Transcutaneous vagus nerve stimulation (e.g., Stivax device) for post-laminectomy syndrome, seizures, and all other indications; Experimental, investigational, or unproven: VNS and transcutaneous VNS for chronic migraine attack prevention; Experimental, investigational, or unproven: VNS and transcutaneous VNS for prevention/attenuation of myocardial ischemia-reperfusion injury; Experimental, investigational, or unproven (not an all-inclusive list): VNS and transcutaneous VNS for addictions; Experimental, investigational, or unproven: VNS and transcutaneous VNS for Alzheimer disease; Experimental, investigational, or unproven: VNS and transcutaneous VNS for anxiety disorders; Experimental, investigational, or unproven: VNS and transcutaneous VNS for atonic seizures; Experimental, investigational, or unproven: VNS and transcutaneous VNS for atrial fibrillation; Experimental, investigational, or unproven: VNS and transcutaneous VNS for autism; Experimental, investigational, or unproven: VNS and transcutaneous VNS for bipolar disorders; Experimental, investigational, or unproven: VNS and transcutaneous VNS for bulimia nervosa; Experimental, investigational, or unproven: VNS and transcutaneous VNS for cancer; Experimental, investigational, or unproven: VNS and transcutaneous VNS for cerebral palsy; Experimental, investigational, or unproven: VNS and transcutaneous VNS for Crohn's disease; Experimental, investigational, or unproven: VNS and transcutaneous VNS for chronic headaches; Experimental, investigational, or unproven: VNS and transcutaneous VNS for cluster headaches; Experimental, investigational, or unproven: VNS and transcutaneous VNS for cognitive impairment associated with Alzheimer's disease; Experimental, investigational, or unproven: VNS and transcutaneous VNS for coma; Experimental, investigational, or unproven: VNS and transcutaneous VNS for COVID-19; Experimental, investigational, or unproven: VNS and transcutaneous VNS for depression (including post-partum depression); Experimental, investigational, or unproven: VNS and transcutaneous VNS for Dravet syndrome; Experimental, investigational, or unproven: VNS and transcutaneous VNS for dysphagia; Experimental, investigational, or unproven: VNS and transcutaneous VNS for eating disorders (anorexia and bulimia); Experimental, investigational, or unproven: VNS and transcutaneous VNS for essential tremor; Experimental, investigational, or unproven: VNS and transcutaneous VNS for fibromyalgia; Experimental, investigational, or unproven: VNS and transcutaneous VNS for gastroparesis; Experimental, investigational, or unproven: VNS and transcutaneous VNS for generalized motor seizures (formerly generalized tonic-clonic seizures); Experimental, investigational, or unproven: VNS and transcutaneous VNS for generalized epilepsy syndromes; Experimental, investigational, or unproven: VNS and transcutaneous VNS for generalized treatment-resistant epilepsy; Experimental, investigational, or unproven: VNS and transcutaneous VNS for heart failure; Experimental, investigational, or unproven: VNS and transcutaneous VNS for hemicrania continua; Experimental, investigational, or unproven: VNS and transcutaneous VNS for impaired glucose tolerance/pre-diabetes; Experimental, investigational, or unproven: VNS and transcutaneous VNS for inflammation; Experimental, investigational, or unproven: VNS and transcutaneous VNS for intractable hiccups; Experimental, investigational, or unproven: VNS and transcutaneous VNS for juvenile myoclonic epilepsy; Experimental, investigational, or unproven: VNS and transcutaneous VNS for migraine headaches; Experimental, investigational, or unproven: VNS and transcutaneous VNS for mood disorders; Experimental, investigational, or unproven: VNS and transcutaneous VNS for narcolepsy; Experimental, investigational, or unproven: VNS and transcutaneous VNS for obesity; Experimental, investigational, or unproven: VNS and transcutaneous VNS for obsessive-compulsive disorder; Experimental, investigational, or unproven: VNS and transcutaneous VNS for panic disorder; Experimental, investigational, or unproven: VNS and transcutaneous VNS for post-traumatic stress disorder; Experimental, investigational, or unproven: VNS and transcutaneous VNS for Prader-Willi syndrome; Experimental, investigational, or unproven: VNS and transcutaneous VNS for rheumatoid arthritis; Experimental, investigational, or unproven: VNS and transcutaneous VNS for schizophrenia; Experimental, investigational, or unproven: VNS and transcutaneous VNS for Sjogren's syndrome; Experimental, investigational, or unproven: VNS and transcutaneous VNS for sleep disorder; Experimental, investigational, or unproven: VNS and transcutaneous VNS for status epilepticus; Experimental, investigational, or unproven: VNS and transcutaneous VNS for stroke; Experimental, investigational, or unproven: VNS and transcutaneous VNS for tinnitus; Experimental, investigational, or unproven: VNS and transcutaneous VNS for Tourette's syndrome; Experimental, investigational, or unproven: VNS and transcutaneous VNS for traumatic brain injury (TBI), including post-TBI pneumonia; Experimental, investigational, or unproven: VNS and transcutaneous VNS for vestibular migraine; Experimental, investigational, or unproven: VNS and transcutaneous VNS for all other indications not listed as medically necessary (list is not all-inclusive). Claims may be denied when the requested service falls under these.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT