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HCPCS/CPT K1020, Non-invasive vagus nerve stimulator | No Prior Auth

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`K1020`, Non-invasive vagus nerve stimulator

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Prescription from a healthcare provider required to load the device with days of therapy (refill card).
Clinical documentation supporting the reason for pulse generator removal (e.g., device malfunction, intolerable side effects, signs of infection, or lack of efficacy).
Providers must reference the most up-to-date CPT manuals and professional coding guidance prior to submission of claims for reimbursement.
Refer to the applicable state Medicaid manual for any Medicaid coverage provisions that may override this policy.

Key Coverage Criteria

Adjunctive therapy for medically refractory epilepsy using chronic intermittent stimulation of the left vagus nerve.
Adjunctive therapy for treatment-resistant major depressive disorder (FDA-approved).
Diagnosis of focal onset (formerly partial onset) seizures or generalized onset seizures.
Intractable epilepsy defined by failure of at least one year of adherent therapy with at least two anti-seizure drugs and continued seizures that have a major impact on activities of daily living.
Member is not a suitable candidate for, is opposed to, or has failed epilepsy surgery.
Request is for an FDA‑approved VNS device.

1 Active Policy

AMBETTER-CP.MP.12, Vagus Nerve Stimulation

Related Codes

61886(1 policies)61888(1 policies)64553(1 policies)64568(1 policies)64569(1 policies)64570(1 policies)C1767(1 policies)61885(1 policies)

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Review CMS resources (NCDs, LCDs, and Medicare Coverage Articles) on the CMS website prior to applying this policy to Medicare members.