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Anthem Blue Cross Blue Shield / Elevance (Commercial) · peripheral nerve stimulation

v1verified 2026-07-24manual-pull source

✗ investigational / not covered · commercial

Criteria checklist

0 of 5 ticked
Indications
  • enumerated: yes
  • covered:
    • investigational:
      • implantable peripheral nerve stimulation devices for pain — investigational and not medically necessary for anyone not meeting the ReActiv8 criteria, and in all other situations
      • named devices considered investigational: SPRINT, StimRouter, StimQ, Nalu
    Conservative care
    • required: not stated in the policy
    • note: n/a — not covered
    Trial
    • required: no
    • min duration days: not stated in the policy
    • success criteria: not stated in the policy
    • threshold is binding: no
    Psychological evaluation
    • required: no
    • must clear: no
    • note posture: n/a
    Quantity limits
    • applies: no
    Payor-specific notes

    Anthem SURG.00158 deems implantable PNS investigational/not medically necessary for all situations EXCEPT ReActiv8 restorative neurostimulation (separate cell). Named investigational devices: SPRINT, StimRouter, StimQ, Nalu. This is MORE restrictive than Medicare, which covers PNS under NCD 160.7-A for chronic intractable peripheral-nerve pain. From the fetched Anthem policy.

    Ticks are a documentation aid — nothing is stored; they reset on reload.

    Dot phrase

    Anthem (SURG.00158) deems implantable PNS **investigational/not medically necessary** (SPRINT, StimRouter, StimQ, Nalu) — except ReActiv8 (see `.REACTIV8ANTHEM`).

    .PNSANTHEM
    This patient would be a candidate for peripheral nerve stimulation, but generic PNS is not a
covered benefit under this plan: Anthem SURG.00158 deems implantable PNS investigational and
not medically necessary (SPRINT, StimRouter, StimQ, Nalu). My clinical rationale is documented
here: *** . I have considered whether the case instead fits ReActiv8, which is covered (see
.REACTIV8ANTHEM), and discussed alternatives with the patient. Any appeal must contest the
investigational determination itself.

    Cautions

    • Medicare covers PNS under NCD 160.7-A — relevant if the patient has Medicare.
    • Regenerate if `anthem-commercial-pns.md` `version` advances.

    Prior-auth pathway

    • required: not stated in the policy
    • note: n/a — denied as investigational

    Provenance

    Report an issue with this cell

    Change history

    • 2026-07-24anthem pns/reactiv8/itdd: verified live via browser (JS-gated HTML) - SURG.00158 + CG-SURG-79 dates & criteria unchanged; last_verified 2026-07-24 (itdd needs_reverification kept: local-instance adoption unconfirmable) 6ab4f64dcd
    • 2026-06-29Add commercial PNS cells: Anthem, UHC, Cigna (all deny generic PNS) afaa8358cc