Effective August 1, 2025: New Prior Authorization Requirement for Certain Neurostimulators

Date: 05/01/25

Superior HealthPlan and Ambetter from Superior HealthPlan will require prior authorization for certain neurostimulator procedures for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter 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 updates is effective on August 1, 2025.

Medicaid Required Prior Authorization:

CPT Code	CPT Description	Criteria
64555	Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)	CP.MP.117  Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation This policy can be found on Superior’s Clinical, Payment & Pharmacy Policies webpage.

Medicaid and Ambetter Required Prior Authorization:

CPT Code	CPT Description	Criteria
L8686	Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension	CP.MP.117 Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation This policy can be found on Superior’s Clinical, Payment & Pharmacy Policies webpage.

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.