CLV IntelligenceReimbursement Policy Evidence

Medicare prior authorization · 33276

33276 — Phrenic Nerve Stimulator

Subject to WISeR prior authorization or pre-payment review in AZ, NJ, OH, OK, TX, WA for dates of service 2026-01-15 through 2031-12-31, in hospital outpatient, ambulatory surgical center, office and home settings. The decision is made on Medicare’s existing coverage policy; nothing in these programs changes what is covered.

WISeR

Decision
3 days; 2 days expedited; unlimited resubmissions
If no request is made
the claim goes to pre-payment medical review
Policies CMS cites (Appendix A)
NCD 160.19
Participant by state
AZ: Zyter · NJ: Genzeon · OH: Innovaccer · OK: Humata Health · TX: Cohere Health · WA: Virtix Health
Exemption
NPI-level, after ≥10 requests and the participant’s affirmation-rate threshold in an assessment period; granted quarterly from July 2026; held at least a year.

What CMS lists for the record

From the WISeR Operational Guide, verbatim. The coverage policy governs; use the check below for the diagnosis and state.

CMS WISeR documentation checklist · §6.2.4

Operational Guide v7.0, last updated July 24, 2026 · retrieved 2026-09-14

Phrenic Nerve Stimulator (NCD 160.19)

CMS: “To meet coverage criteria, the patient’s medical record must contain documentation that fully supports the medical necessity of services. Subsections 6.2.1 to 6.2.13 list the documentation requirements for example services. For detailed documentation requirements, providers who choose to submit a prior authorization request for a WISeR Select Item or Service should refer to the relevant NCDs and/or their MAC jurisdiction’s LCDs and Local Coverage Articles (LCAs), if available, for guidance. They can be found on the Medicare Coverage Database website.”

For hypoventilation caused by respiratory paralysis resulting from lesions of the brainstem and cervical spinal cord (interruption of neuronal conduction at or above the C3 vertebral level), congenital central hypoventilation syndrome, and other disorders with ventilatory insufficiency (in which there is dependence on intermittent or permanent use of a mechanical ventilation as well as maintenance of a permanent tracheotomy stoma), the general documentation requirements for initial implantation of a phrenic nerve stimulator are as follows:

  • Documentation of the etiology of ventilatory insufficiency as well as evaluation (e.g., of diaphragmatic function) and management to date, including the use of mechanical ventilation
  • Documentation of intact phrenic nerve and diaphragmatic function, e.g., through a percutaneous nerve conduction study
  • Documentation of absence of severe underlying primary pulmonary disease through history and exam, prior and current chest imaging, and pulmonary function testing (when feasible) For central sleep apnea (CSA), the general documentation requirements for initial implantation of a phrenic nerve stimulator are as follows:
  • Documentation of etiology of CSA as idiopathic/primary or heart-failure–related CSA (not opioid- or medication-induced)
  • Documentation of moderate to severe CSA confirmed by polysomnography
  • Documentation of failure of, intolerance of, or contraindication to at least one of the following: a) Continuous positive airway pressure (CPAP) b) Bilevel positive airway pressure (BiPAP) c) Adaptive servo-ventilation (ASV) d) Nocturnal oxygen (for patients who have hypoxemia while sleeping)
  • For patients with heart failure (HF): documentation of New York Heart Association (NYHA) class, left ventricular ejection fraction (LVEF), and stable, optimized guideline‐directed medical therapy (GDMT) as applicable
  • Documentation of plan for device interaction testing if patient has an implantable cardioverter-defibrillator (ICD), cardiac resynchronization therapy (CRT), or pacemaker
  • Assessment and documentation of none of the following contraindications: a) Active infection b) NYHA IV HF or American College of Cardiology (ACC)/American Heart Association (AHA) Stage D c) Recent stroke/transient ischemic attack (TIA) d) Currently on renal dialysis or severe renal disease e) Phrenic nerve palsy or other anatomic barriers f) Opioid or other medication-induced CSA
Read the guide on CMS →

The coverage policy the reviewer applies, by state

Each state’s Medicare contractor writes its own LCD, so the policy that decides a 33276 request depends on the state. The documentation requirements below are quoted from the policy or its Billing & Coding article as captured; the linked CMS document is authoritative.

All WISeR states (AZ, NJ, OH, OK, TX, WA) · national coverage determination

NCD 160.19 — Phrenic Nerve Stimulator · CMS version 1 · captured 2026-09-13

Read the documentation requirements in the linked CMS document.

Check 33276 for your state, diagnosis and setting

The governing policy as it stands today, whether the diagnosis is on its list, and the documentation the policy’s own text requires — quoted, source-linked, free.

Run the check →

Full lists: WISeR code list · WISeR rules and exemption

Same family: 33277

Sources: CMS WISeR Provider and Supplier Operational Guide v7.0 (2026-07-24), Appendix A; CMS list of OPD services requiring prior authorization (2024-08-05); CMS list of ambulatory surgical center services for prior authorization (2026-03-05) and the ASC Operational Guide (2026-03-03). Codes are shown as numbers only, as CMS lists them. CPT® is a registered trademark of the American Medical Association.