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Effective 3/31/26: Update to Review Criteria for Certain Neurostimulators

Date: 01/30/26

Superior HealthPlan will update the medical necessity review criteria of Certain Neurostimulators for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP members.

Superior ensures medical necessity review criteria is current and appropriate for members and the scope of services provided, as a result, the following code update is effective on March 31, 2026.

CPT Code

CPT Description

 Criteria

64555

Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)

Medicaid:  Texas Medicaid Provider Procedures Manual

CHIP:  Change Healthcare’s InterQual criteria, proprietary, but   available upon request.

L8686

Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension

To review prior authorization requirements, please visit Superior’s Prior Authorization webpage.

For questions or additional information, contact Superior’s Prior Authorization department at 1-800-218-7508.