A4540 Trans elec nerv periph nervDistal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper arm
Status N: non-covered service.
A4540 appears in 20 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Shield of California, BlueCross BlueShield of South Carolina, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Headaches: Nonsurgical Management (0462) | not covered | Jul 23, 2026 | payer document |
| Anthem | Surface Electrical Stimulation Devices for Headache and Migraine (CG-MED-100) | covered if criteria are met | Feb 19, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Remote Electrical Neuromodulation For Migraines (A.7.01.171) | listed, no stance | payer document | |
| Blue Cross & Blue Shield of Rhode Island | Remote Electrical Neuromodulation for Migraines | covered if criteria are met | Jun 1, 2026 | payer document |
| Blue Shield of California | Remote Electrical Neuromodulation for Migraines (7.01.171) | listed, no stance | payer document | |
| BlueCross BlueShield of South Carolina | Remote Electrical Neuromodulation for Migraines (CAM 701171) | listed, no stance | Jun 1, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Remote Electrical Neuromodulation for Migraines (SUR701.046) | listed, no stance | Dec 15, 2025 | payer document |
| Premera Blue Cross | Remote Electrical Neuromodulation for Migraines (7.01.171) | listed, no stance | Sep 21, 2026 | payer document |
| UnitedHealthcare | Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (2026T0080TT) | listed, no stance | Sep 10, 2026 | payer document |
| UnitedHealthcare | Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (CS086.AC) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for Idaho Only) (CS086ID.B) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for Kansas Only) (CS086KS.03) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for Kentucky Only) (CS086KY.13) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for Nebraska Only) (CS086NE.AC) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for New Jersey Only) (CS086NJ.Y) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for New Mexico Only) (CS086NM.D) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for North Carolina Only) (CSNCT0080.06) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for Ohio Only) (CS086OH.E) | listed, no stance | Dec 1, 2025 | payer document |
| UnitedHealthcare | Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for Pennsylvania Only) (CS086PA.Z) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for Tennessee Only) (CS086TN.AA) | listed, no stance | Sep 1, 2026 | payer document |
Prior authorization required or conditional in CO, IN, OH.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.