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.
4.6 Stereotactic Laser Amygdalohippocampectomy
(SLAH), including via Magnetic Resonance Imaging (MRI)-guided Laser
Interstitial Thermal Therapy (LITT), may be considered for cost-sharing
for the treatment of Mesial Temporal Lobe Epilepsy (MTLE) when performed
in accordance with American Society for Stereotactic and Functional
Neurosurgery (ASSFN) recommendations. The effective date is February
1, 2022.
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 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.
