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 (Healthcare Common Procedure Coding System (HCPCS)
code 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 External trigeminal nerve stimulation
(eTNS), also referred to as transcutaneous supraorbital neurostimulation
(t-SNS), for the prevention and/or treatment of migraines is unproven.
5.4 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.
5.5 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.
5.6 Off-label
use of eTNS for the treatment of PTSD is excluded.