Medical Policy Updates

Notification of Policy Revisions Effective August 10, 2021 Posted June 1, 2021

Medical Policy	Revision
Facet Joint Denervation “Notification”	Policy Guidelines item 5 updated with “Prior success is defined as 50% or more pain relief documented in medical record”. References added. Code 64625 added to Billing/Coding section. Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021. Notification 6/1/2021 for effective date 8/10/2021.
Neurostimulation, Electrical “Notification”	Additional sections titled “Peripheral Subcutaneous Field Stimulation” and “Threshold Electrical Stimulation” added to policy. Related policies updated. Policy statement updated to read “Functional Neuromuscular Electrical Stimulation, Peripheral Subcutaneous Field Stimulation, Neuromuscular Electrical Stimulation, and Threshold Electrical Stimulation are considered investigational for all applications”. Medical Director review. Policy noticed 6/1/2021 for effective date 8/10/2021.