Tonic Motor Activation for Restless Legs Syndrome

BCBS Montana · PayerPolicy · BCBSMT-DME101.053

Summary of the payer’s published policy. Not a coverage determination — confirm with BCBS Montana before submitting.

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Codes in this policy

Each code’s status is what the policy records for it. This page does not show the policy’s criteria. Read them in the payer’s source.

Codes this policy lists and each code’s status in the policy
Code	Code system	Status in this policy
A4544	HCPCS	Covered
E0743	HCPCS	Covered