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 Non-invasive
vagus nerve stimulation (nVNS), also referred to as transcutaneous
vagus nerve stimulation (tVNS), for the preventive and acute treatment
of migraine and cluster headache 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.
5.5 Off-label use
of eTNS for the treatment of PTSD is excluded.
5.6 Monoclonal antibodies (such
as aducanumab) for the prevention, treatment, or mitigation of symptoms
related to Mild Cognitive Impairment (MCI) or Alzheimer’s disease
(AD) is unproven.