Does A4540 require prior authorization?

Yes, A4540 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for A4540?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`A4540`, Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

When making coverage determinations, review the member's benefit contract or Summary Plan Description (SPD) for coverage definitions, exclusions, and benefit limitations (e.g., dollar or duration caps).

Key Coverage Criteria

Covered indications: For treating pain due to malignancy involving the head and neck, (1) injection of local anesthetics and/or steroids used as greater occipital nerve blocks (GONBs) and (2) occipital nerve ablation (destruction by neurolytic agent).
Initial use of the Nerivio®remote electrical neuromodulation (REN) device for the treatment of migraine is consideredmedically necessaryin individuals who meet ALL of the following criteria:

Eight years of age or older;and

Six-month history of headaches that meet International Classification of Headache Disorders (ICHD 3-beta) diagnostic criteria for migraine with or without aura;and

Meets one of the following two criteria:Nerivio is used to treat acute migraine;orNerivio is used to prevent migraine for individuals with 6 to 24 headache days (defined as a calendar day with headache regardless of severity or duration) per 28-day period in each of the 3 months preceding use of Nerivio.

Nerivio is used to treat acute migraine;or

11 Active Policies

ANTHEM-DME.00011, Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

ANTHEM-CG-MED-100, Surface Electrical Stimulation Devices for Headache and Migraine

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

UHC-POL-occipital-neuralgia-headache-treatment, Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache)

BCBSIL-SUR701.046, Remote Electrical Neuromodulation for Migraines

BCBSMT-SUR701.046, Remote Electrical Neuromodulation for Migraines

BCBSNM-SUR701.046, Remote Electrical Neuromodulation for Migraines

BCBSOK-SUR701.046, Remote Electrical Neuromodulation for Migraines

REGENCE-MED143, Transcutaneous Electrical Modulation Pain Reprocessing

UMR-POL-UMR-occipital-neuralgia-headache-treatment, Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache)

SUREST-POL-SUREST-occipital-neuralgia-headache-treatment, Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache)

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A4540, Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves