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Medical Policy Implementation: Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy

Effective July 22, 2015, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for the treatment of refractory partial epilepsy.

Based on the guidelines of our medical policy, Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy, claims for dates of service on and after July 22, 2015 will be processed as indicated below:

For patients age 18 years and older

  • Claims for dates of service on and after July 22, 2015 that include CPT® codes 61850, 61860, 61870, 95970 or 95971 and one or more of the diagnosis codes listed below will pend while information required to determine medical appropriateness is requested and reviewed.

ICD-9 diagnosis codes: 345.40, 345.41, 345.50, 345.51, 345.70, 345.71
ICD-10 diagnosis codes: G40.201, G40.209, G40.211, G40.219, G40.001, G40.009, G40.101, G40.109, G40.011, G40.019, G40.111, G40.119, G40.509

  • Claims for dates of service on and after July 22, 2015 that include CPT codes 61863, +61864, 61867, +61868, 61880 or 61886 and one or more of the diagnosis codes listed below will pend while information required to determine medical appropriateness is requested and reviewed.

    CPT codes 61863, +61864, 61867, +61868, 61880 or 61886 submitted on claims for patients age 18 years and older for dates of service July 22, 2015 and after that include a diagnosis code other than one of those listed below will be denied as experimental/investigational services/procedures.

ICD-9 diagnosis codes: 332.0, 332.1, 333.1, 333.6, 333.71, 333.89, 723.5, 345.40, 345.41, 345.50, 345.51, 345.70, 345.71
ICD-10 diagnosis codes: G20, G21.4, G21.11, G21.19, G21.2, G21.3, G21.8, G21.9, G24.1, G24.9, G25.0, G25.2, G40.201, G40.209, G40.211, G40.219, G40.001, G40.009, G40.101, G40.109, G40.011, G40.019, G40.111, G40.119, G40.509, G80.3, M43.6

For patients under age 18 years

  • CPT codes 61850, 61860, 61870, 95970, 95971, 61863, +61864, 61867, +61868, 61880 or 61886 included on claims for services provided on and after July 22, 2015 will be denied as experimental/investigational services/procedures regardless of the diagnosis code(s) included on the claim.

Review this revised policy in our online Medical Policy Manual.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after July 22, 2015.

CPT® is a registered mark of the American Medical Association.

Published on: April 22, 2015, 10:00 a.m. ET
Last updated on: November 24, 2020, 23:35 p.m. ET