Does L8688 require prior authorization?

Yes, L8688 requires prior authorization (high confidence). Code explicitly requires prior authorization.

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`L8688`, Implantable neurostimulator pulse generator, dual array, non-rechargeable,

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Documentation Required

Claims may require medical records documentation to assess whether the member meets the clinical criteria for coverage; however, documentation does not guarantee coverage.
Documentation of severe, chronic respiratory failure requiring mechanical ventilation and the specific qualifying diagnosis (alveolar hypoventilation from brainstem disorder OR interruption of neuronal conduction at/above C3) or, for NeuRx, documentation of stable high spinal cord injury.
Evidence of intact/integrity of the intrathoracic section of the phrenic nerve (e.g., phrenic nerve EMG, nerve conduction studies).
Evidence diaphragm is stimulable and diaphragmatic function is sufficient to accommodate chronic stimulation (e.g., diaphragm EMG, fluoroscopic demonstration of diaphragm movement with stimulation).
Baseline estimated pulmonary function test results known or documentation explaining why baseline estimate is likely adequate.
Clinical documentation of normal chest anatomy, normal level of consciousness, and patient ability/willingness to participate in training and rehabilitation.

Key Coverage Criteria

Deep brain stimulation is proven and medically necessary for treating dystonia, essential tremor, Parkinson disease, and refractory epilepsy for a partial or focal seizure disorder.
Covered indication: Implanted electrical spinal cord stimulators are medically necessary for CRPS, painful diabetic neuropathy, and failed back surgery syndrome when performed per FDA-labeled indications and cautions.
Sacral Nerve Stimulation (neurostimulation) screening trial is proven and medically necessary for treating urinary voiding dysfunction when all the following criteria are met: Lower urinary tract symptoms, as indicated by one or more of the following: Overactive bladder symptoms, Urge Incontinence, Nonobstructive urinary retention; Bladder capacity ≥100 mL; No neurologic cause; No bladder outlet obstruction; Symptoms refractory to conservative care; Individual capable of operating the device.
Implantable vagus nerve stimulators are proven and medically necessary for treating epilepsy in individuals who have medically refractory seizures with failure of two or more trials of antiseizure drugs (or intolerable AED effects), are not candidates for epilepsy surgery (or have failed/refuse after shared decision making), and have no history of left or bilateral cervical vagotomy.
Avery Diaphragm Pacing System (previously Mark IV) is medically necessary as an alternative to invasive mechanical ventilation for an individual with severe, chronic respiratory failure requiring mechanical ventilation for EITHER: alveolar hypoventilation (primary or secondary to a brainstem disorder) OR interruption of neuronal conduction at the upper cervical level, at or above the C3 vertebral level.
Avery Diaphragm Pacing System when ALL of the following are met: integrity of the intrathoracic section of the phrenic nerve; diaphragmatic function sufficient to accommodate chronic stimulation; baseline estimated pulmonary function test is known, or likely, to be adequate; individual has normal chest anatomy, normal level of consciousness, and the ability to participate in and complete the training and rehabilitation associated with the use of the device.

20 Active Policies

ANTHEM-SURG.00129, Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

ANTHEM-SURG.00026, Deep Brain, Cortical, and Cerebellar Stimulation

ANTHEM-SURG.00158, Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

ANTHEM-CG-SURG-70, Gastric Electrical Stimulation

EVICORE-HPLAN-CIGNA-AFCE721BA4F3, Cigna Comprehensive Code List - Effective 03/07/2026

EVICORE-HPLAN-CIGNA-844835841DE9, Cigna Commercial Interventional Pain Management Code List - Effective 03/07/2026

EVICORE-HPLAN-CIGNA-47DEF0053A7B, Cigna Commercial Sleep Management Code List - Effective 03/07/2026

EVICORE-HPLAN-CIGNA_MEDICARE-47F76AA38AE6, Cigna Medicare Advantage Interventional Pain Management Code List - Effective 01/01/2025

CARELON-interventional-pain-management-2024-06-30-for-ohio-medicaid, Interventional Pain Management

CARELON-interventional-pain-management-2025-07-26-for-anthem-bc-ca-commercial, Interventional Pain Management

CARELON-interventional-pain-management-2026-06-14, Interventional Pain Management

CARELON-sleep-disorder-management-2024-10-20-updated-2025-07-01-for-anthem-bcbs-ohio-medicaid-and-regence-only-deferred-to-2025-12-01, Sleep Disorder Management

CARELON-sleep-disorder-management-2025-11-15-updated-2026-07-01, Sleep Disorder Management

CIGNA-0391, Diaphragmatic/Phrenic Nerve Stimulation

UHC-POL-deep-brain-cortical-stimulation, Deep Brain and Cortical Stimulation

UHC-POL-electrical-stimulation-treatment-pain-muscle-rehabilitation, Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation

UHC-POL-implanted-electrical-stimulator-spinal-cord, Implanted Electrical Stimulator for the Spinal Cord

UHC-POL-sacral-nerve-stimulation, Sacral Nerve Stimulation for Urinary and Fecal Indications

UHC-POL-vagus-nerve-stimulation, Vagus and External Trigeminal Nerve Stimulation

UHCMA-POL-UHC_MA-deep-brain-responsive-cortical-stimulation, Deep Brain and Responsive Cortical Stimulation

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L8688, Implantable neurostimulator pulse generator, dual array, non-rechargeable,