Neurology and Neurosurgery MEDICAL POLICY GROUP Co-chairs Ben Kruskal, MD, PhD, FAAP, FIDSA Medical Director for Clinical Operations Stephanie Klimov, Clinical Pharmacist, Pharmacy Operations

January 27th, 2026 12-2 pm Conference call only.
Please email ebr@bcbsma.com for more information.

Invited: Benjamin Kruskal, MD, PhD, FAAP, FIDSA, co-chair (Medical Director, Clinical Operations); Ashley Yeats, MD (Vice President, Medical Operations); Satya Dondapati, MD (Senior Medical Director, Medical Operations); Theresa Rines, CPC (Director, Medical Policy Administration); Adam Licurse, MD (Senior Medical Director, Medical Operations); Grace Baker, MSW, LCSW (Medical Policy Administration); Shelby Patterson, RN, BSN, (Medical Policy Administration); Ka Lee Yang, RN, BSN (Medical Policy Administration); Dr. Ika Noviawaty;

Invited Physician Guest(s): Representatives from the Massachusetts Society of Neurology and Neurosurgery

Policies with Upcoming Coverage Changes Spine Fusions: Cervical, Lumbar, and Thoracic (226)

Effective April 1, 2026 New medical policy describing medically necessary indications for spine fusions cervical, lumbar and thoracic will be used. Prior authorization is not changing. Prior authorization is still required.
InterQual criteria for fusion: cervical, lumbar and thoracic will not be applicable effective 4.1.26. InterQual criteria for decompression/spine fusion: cervical, lumbar and thoracic will only be applicable for the following procedures: • Corpectomy • Facetectomy • Foraminotomy • Hemilaminectomy • Discectomy • Laminectomy • Laminoforaminotomy • Laminoplasty • Laminotomy • Microdiscectomy • Transpedicular Decompression Tonic Motor Activation for Restless Legs Syndrome (224) Effective March 1, 2026 New medical policy describing investigational indications. Tonic motor activation as a treatment for restless legs syndrome refractory to medication is considered investigational. Remote Electrical Neuromodulation for Migraines (145) Effective March 1, 2026 Policy revised to include preventive treatment continuation of use criteria. Policies with Coverage Updates in the Past 12 Months Carelon Advanced Imaging Radiology CPT and HCPCS Codes (900)

Magnetoencephalography recording and analysis codes 95965; 95966 added. These codes require prior authorization through Carelon. 11/2025

Deep Brain Stimulation (473) Policy updated with literature review through March 4, 2025; references added. Investigational policy statement added for adaptive deep brain stimulation in Parkinson disease. Investigational statements for deep brain stimulation for neurological and psychiatric conditions clarified. Effective 9/1/2025. 11/2025. Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures (498) Clarified coding information. 11/2025. Hyperbaric Oxygen Pressurization (HBO) (653)

Annual policy review. Policy updated with literature review through June 7, 2024. References added. Clinical input added. Based on results of structured request for clinical input, treatment of necrotizing soft tissue infections, idiopathic sudden sensorineural hearing loss, and central retinal artery occlusion added to medically necessary statement. Coding clarified. Effective 2/1/2025. 11/2025. Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease (171) Clarified coding information. 11/2025. Remote Electrical Neuromodulation for Migraines (145) New medical policy describing medically necessary indications for remote electrical neuromodulation using Nerivio™. Effective 2/1/2025. 11/2025. Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy (716) Clarified coding information. 11/2025. Vagus Nerve Stimulation (474)

Investigational statements clarified. 9/1/2025. 11/2025.

Policies with No Coverage Updates

1. Allograft Injection for Degenerative Disc Disease (838)
2. Artificial Intervertebral Disc: Lumbar Spine (592)
3. Automated Percutaneous and Percutaneous Discectomy (231)
4. Autonomic Nervous System Testing (713)
5. Axial Lumbosacral Interbody Fusion (AxiaLIF) (404)
6. Biofeedback for the Treatment of Headache (152)
7. Carotid Stent placement (219)
8. Chelation Therapy (122)
9. Cognitive Rehabilitation (660)
10. Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) (271)
11. Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis (352)
12. Diagnostic Laboratory Services (139)
13. Dynamic Posturography to Assess Vestibular Dysfunction (263)
14. Dynamic Spinal Visualization and Vertebral Motion Analysis (195)
15. Electrical Stimulation for the Treatment of Arthritis (302)
16. Endovascular Procedures (Angioplasty and/or Stenting) for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) (323)
17. Functional Neuromuscular Electrical Stimulation (201)
18. Image Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis (240)
19. Interferential Stimulation for Treatment of Pain (509)
20. Interferons Alpha and Gamma (052)
21. Interspinous Distraction Devices (Spacers) (584)
22. Intravenous anesthetics for the treatment of chronic pain (291)
23. Laser Interstitial Thermal Therapy

24. Neural Therapy (914)
25. Paraspinal Surface Electromyography (SEMG) to Evaluate and Monitor Back Pain (517)
26. Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy and Restorative Neurostimulation Therapy (172)
27. Peripheral Subcutaneous Field Stimulation (513)
28. Pregabalin (Lyrica® and Lyrica® CR (057)
29. Quantitative Sensory Testing (258)
30. Sensory Integration Therapy (659)
31. Serum Biomarker Panel Testing for Systemic Lupus Erythematosus (702)
32. Sphenopalatine Ganglion Block for Headache (026)
33. Surgical Deactivation of Migraine Headache Trigger Sites (801)
34. Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies (634)
35. Vertebral Axial Decompression (603)
36. Whole Body Computed Tomography Scan as a Screening Test (447)

37. Zolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular Atrophy (008)

    Reference Policies Policy 072 - Outpatient Prior Authorization Code List New policy outlining procedure codes that require prior authorization when performed in the outpatient setting.

    Policy 132 – Medicare Advantage Management
    New policy outlining associated Medicare National Coverage Determinations and Local Coverage Determinations.
    Medicare Advantage Part B Step Therapy (020)

    New medical policy outlining associated non-oncology indications for drugs with both oncology and non-oncology indications. For the management of oncology or supportive care indications, please see related policies above that are managed by AIM (Medical Policy #099 and #105). Medicare Advantage Part B Utilization Management (125)

    New policy outlining associated Medicare Advantage Part B Medical Utilization Management for treatments requiring Prior Authorization.
    Pharmacy Policy 033 – Med UM policy

    Medical Utilization Management (MED UM) and Pharmacy Prior Authorization Policy Pharmacy Policy 034 - MED UM Drug List

    Medications requiring prior authorization when covered under the members medical benefits and administered in a clinician’s office, outpatient setting, or by the home infusion therapy provider
    Carelon Medical Benefits Management Clinical Appropriateness Guidelines (formerly AIM Specialty Health) Carelon (formerly AIM) Advanced Imaging/Radiology Policy #968
    Brain Imaging CPT, HCPCS and Diagnoses Codes list - Medical Policy

    931

    Head and Neck Imaging CPT, HCPCS and Diagnoses Codes list - Medical Policy #934

    For questions: ebr@bcbsma.com