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TRICARE Policy Manual 6010.60-M, April 1, 2015
Medicine
Chapter 7
Section 15.1
Neurology And Neuromuscular Services
Issue Date:  April 19, 1983
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-61, April 17, 2020
1.0  CPT PROCEDURE CODEs
20552, 20553, 95812 - 95999
2.0  HCPCS Procedure Code
J9310
3.0  DESCRIPTION
The diagnosis and treatment of muscle and nerve disorders.
4.0  POLICY
4.1  Neurology and neuromuscular services are covered.
4.2  The Epley Canalith Repositioning Procedure (CRP) is covered for the treatment of Benign Paroxysmal Positional Vertigo (BPPV) with an effective date of June 13, 2012.
4.3  Off-label use of rituximab may be considered for cost-sharing for the treatment of Chronic Inflammatory Demyelinating Polyneuropathy (CIDP). The effective date is July 16, 2010.
4.4  Off-label use of rituximab injections may be considered for cost-sharing for the treatment of Stiff Person Syndrome. The effective date is March 31, 2005.
4.5  Off-label use of rituximab injections may be considered for cost-sharing for the treatment of Multiple Sclerosis (MS). The effective date is February 14, 2008.
5.0  Exclusions
5.1  Topographic brain mapping (HCPCS S8040) is unproven.
5.2  Microcurrent Electrical Therapy (MET), Cranial Electrotherapy Stimulation (CES), or any therapy that uses the non-invasive application of low levels of microcurrent stimulation to the head by means of external electrodes for the treatment of anxiety, depression, insomnia, Post-Traumatic Stress Disorder (PTSD), pain, or migraines and electrical stimulation devices used to apply this therapy, are unproven.
5.3  Magnetic Resonance Guided High-Intensity Focused Ultrasound Surgery (MRgFUS) (CPT 0398T) for the treatment of essential tremor is unproven.
5.4  External trigeminal nerve stimulation (eTNS), also referred to as transcutaneous supraorbital neurostimulation (t-SNS), for the prevention and/or treatment of migraines is unproven.
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