Does E0734 require prior authorization?

Yes, E0734 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

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`E0734`, External upper limb tremor stimulator of the peripheral nerves of the wrist

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Documentation Required

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; for WOPD items the supplier must have a signed SWO prior to delivery.
A treating practitioner clinical evaluation (in-person or Medicare-approved telehealth) must be documented prior to initiating therapy.
Document the diagnosis of essential tremor using the applicable Group 1 ICD-10 code(s) as referenced in the LCD-related Policy Article.

Document baseline BF-ADL scores showing >= 3 on at least one eating/drinking/self-care/writing item and document follow-up BF-ADL demonstrating a 1-point improvement in any such item at re-evaluation.

Document pharmacologic treatment history showing at least two medications tried and failed at maximal tolerable dosages or considered and ruled out, with dosages and reasons for failure or contraindication.

Key Coverage Criteria

The beneficiary has a clinical evaluation (in-person or Medicare-approved telehealth) by the treating practitioner prior to receiving an external upper limb tremor stimulator (E0734).
The beneficiary has a diagnosis of essential tremor (ET) as documented using an applicable Group 1 ICD-10 code per the LCD-related Policy Article.
The beneficiary is age 18 years or older.
The beneficiary has no contraindications to external upper limb tremor stimulator therapy as determined by the treating practitioner.
The external upper limb tremor stimulator is prescribed to treat the beneficiary's dominant upper limb.
Baseline tremor severity shows a Bain & Findley Tremor ADL (BF-ADL) score >= 3 on at least one item for eating, drinking, self-care, or writing.

5 Active Policies

ANTHEM-DME.00049, External Upper Limb Stimulation for the Treatment of Tremors

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

L39591, External Upper Limb Tremor Stimulator Therapy

REGENCE-DME83.05, Threshold Electrical Stimulation as a Treatment of Motor Disorders

CIGNA-0160, Electrical Stimulation Therapy and Devices in a Home Setting

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E0734, External upper limb tremor stimulator of the peripheral nerves of the wrist