text:
Brandon Artiles joined WLBT in August 2010 excited to open a new chapter of his career and life on the WLBT AM Report. In addition to anchoring in the morning he enjoys getting out into the community and reporting stories that effect central Mississippi.
Brandon came to Jackson, MS by way of Jackson, TN, where he anchored the morning show and reported for WBBJ-TV for four years. Prior to that Brandon said he received his "graduate degree" working as a photographer and editor for WATE in Knoxville, TN.
Knoxville is also where Brandon received his education, earning a Bachelor's Degree in Communication/Journalism and Electronic Media from the University of Tennessee.
While he is excited about continuing his career in the Magnolia State, Brandon cherishes his Tennessee ties. He'll certainly continue to cheer on the Vols on Saturdays and the Titans on Sundays.
Brandon, along with his wife, Heather, and son, Joey, look forward to becoming a part of the community and opening a new chapter of their lives in Mississippi.
Email Brandon with your story ideas.
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text:
Fit and Flare Slip Style 550
This item is available in stores and online.*
Enhance your shape with this flattering fit and flare slip. The 2-tiered silhouette features a zip up power net waist for a slimming look. A beautifully lace-trimmed bottom creates fullness to accentuate mermaid and trumpet gowns. Nylon. Made in Sri Lanka. Hand wash, dip dry. *This item is available online and in stores. Check store for size availability.
A dress or skirt that is fitted at the top and flairs below the knee. Also known as fishtail or trumpet style.
A dress or skirt that is fitted at the top and flairs below the knee. Also known as fishtail or mermaid style.
A fabric design element that features multiple layers.
customers bought with this dress
Fit and Flare Slip Style 550 41 42
So comfy! Bridal consultant helped me pick this out and it was so comfy! Definitely suggest getting a slip for the form of the dress! September 10, 2013
Good purchase I ordered this slip for my bridesmaids dress to give it an extra lift and it did just that (perfect) Also I put this slip under my wedding gown as well and it was perfect it gave it the look that I was looking for But be sure to order a size up they run small.... No matter your size small or big May 15, 2013
Keeps shape well and trains the train! My dress is a trumpet/mermaid silhouette. I tried on the dress without the slip and then with it on and it does make a difference! First, please keep in mind that whatever your TRUE size is and the size of the dress, the slip size is going to run a lot bigger!!! No idea why but you know, it's bridal dress sizes, I'm wearing a size 10 in the photo for the slip, my dress is an 8, my true size is a 6!!! Also, when you put the slip on you bring it all the way up just under your breast line (if you're wearing a bustier/corset bra it goes over it just under the breast line, helps to keep a more flowing silhouette!). The flare out at the bottom helped to keep the shape of my dress even when I moved and turned around. My dress also has a chapel length train and it helped to keep the train to the back of the dress too! By keeping the shape of the bottom in place, it also kept the train from I guess floating to the front and all over the place if that makes sense! I suggest trying it on and seeing for yourself. Move around and turn with it on while wearing your dress and you'll see what I mean about keeping the train in check too! May 13, 2013
Makes a difference This slip really makes a difference with my dress, it gives me that hourglass figure. I am a size 6 and my slip is a size 12, and it's very fitted. Also, if you are planning on using this slip under your dress, make sure you wear it when they are fitting you for your hemline as it pushes the dress out. Now that my dress is hemmed, if I wore it without the slip, the dress would be too long. The slip comes bundled in a package and is very wrinkled. I had mine steamed out at my local dry cleaner. May 2, 2013
9-12 of 42
*Color & Style representation may vary by monitor. Not responsible for typographical or pictorial errors. Product availability varies by store and online. Some in-store purchases require special order and markdown styles cannot be special ordered. Contact your local store for details.

subset: commoncrawl


text:
We are almost halfway through the first season of Top Gear USA and we are pleased to say that the show is not a complete waste of our time. In fact, we actually enjoy watching it. The clips are informative, the challenges are funny and entertaining, and the opportunity of making fun of Ferrara will never slide past us. We can't help it; we don't really like the guy as the "main" host.
Now that all of that is out of the way, we can move on to the actual show aired. The fourth episode of Top Gear USA takes us through a long review of the Mercedes SLS AMG with Adam Ferrara behind the wheel. Only Ferrara can ruin the Mercedes' camera time. Top Gear UK has Captain Slow, we have Captain Boring. 'Nuff said.
The more interesting part of the show was the two challenges. The first was a race between the Ford F-150 Velociraptor and a HALO jumper while the second was a jumbled mess of two old beaters shooting out paintballs. And by two old beaters, we mean Ferrara and Wood. Just kidding.
Hit the jump to see details on the fourth episode of Top Gear USA.
Car Reviews/Car News
Adam Ferrara - the lucky son of a gun - had the opportunity to review the Mercedes SLS AMG this week and just the thought of that made us twitch with jealousy. This Mercedes is powered by a 6.3-liter V8 engine located front-mid that develops 571 hp and up to 650 Nm of torque. The engine is mated to a seven-speed dual-clutch transmission, and sprints the car from 0 to 60 mph in 3.7 seconds, while top speed goes up to 197 mph.
We think it is safe to say that Ferrara was pretty thrilled that he got the chance to drive the Mercedes and the task of slamming on the accelerator was not wasted on him, but, for him, the downside was that the Mercedes didn't feel as good on the road as it did on the track going 160mph.
The Stig, of course, took the Mercedes SLS AMG on the Top Gear track, ending up with a time of 1:27.6 and sliding in between the Lamborghini Balboni and the Aston Martin V12 Vantage.
Gallery Mercedes-Benz SLS AMG
Big Star Small Car
The man behind the dorky glasses in this week's Small Car segment was none other than Kid Rock, an American singer-songwriter and rapper with a country twist. Wood was back on as the interviewer - our prayers were answered - but the interview was still lacking. Let's face it, the star actually driving the car is the best part so the interview might as well be non-existent.
That being said, Kid Rock was able to produce the fastest lap with a time of 1:43.9. He also gets an award from us for the star that was the most entertaining while driving.
The Challenges
Challenge One
The first challenge of the week began with Tanner Foust getting down and dirty with the Ford F-150 Velociraptor . After that it was a race between the monstrous Velociraptor and a High Altitude Low Opening (HALO) jumper. HALO jumping is a technique used to drop items, including human beings, from high altitudes using a free-fall parachute. The jumper used in this race is so secretive that we think Top Gear would have rather unveiled the identity of the Stig than mess with the privacy of this guy.
Both racers have to travel a distance of five miles to get to the finishline, but the jumper has to get there by falling from an altitude of 25,000 feet while the Ford F-150 - driven by who other than Foust - gets to take a five miles trek on asphalt, rough trail, and open desert. It was a pretty aggressive race, but in the end, the HAL O jumper walked away with the win. For a competitive guy, Foust sure isn't walking away with many wins so far.
The Stig also took the Velociraptor around the Top Gear track because, well just because. The incredibly huge pick-up truck got around the bend with a time of 1:39.0 which is pretty impressive.
Gallery Ford F-150 SVT Raptor R
Challenge Two
In the final segment of the show, the Top Gear USA boys decided to go head to head with some old cars and paintballs. Adam Ferrara showed up in a 1977 Chevy El Camino SS and Wood strolled in with a 1997 Honda Del Sol . Foust was absent during this segment which pretty much took a lot of the fun out of it. Now it was just Dumb and Dumber riding around in two old cars strapped down with paintball guns.
The segment was short and that, along with the Foust absence, made it suffer a bit. We think that the segment could have been so much better if they would have made it longer and made sure all three hosts were there. Foust just adds more of a competitive edge to the challenges. The funniest part of the segment was when Ferrara lost and had to shoot himself in the foot with a paintball gun. Now, that was funny.
Wrapping it Up
Thankfully, the car news segment that was brought out in Episode Three was skipped this week which made this episode of Top Gear USA that much better. We can catch the news any other day of the week. We stay up on Sundays to watch fast cars and cool challenges.
Check in with us next week as we move on to Episode Five of Top Gear USA, and remember to leave some of your thoughts on this episode in the comments section below.


text:
Graduation Day
The names echoed over the loudspeaker system.
Christopher Paul Lankford.
Rebecca Jane Leonard.
Santana stood on the steps of the stage, her eyes darting over the crowd. They had to be here. They'd said they'd try. Today, of all days, they had to be here.
Michael Allen Lockwood.
A loud burst of applause and cheers as a football player crossed the stage and screamed "Titans rule!" before grabbing his diploma. She took advantage of the distraction to keep looking. They should be easy to spot. After all, her parents stood out in this town.
But they weren't here. In the back of her mind, she'd known they wouldn't be. They weren't out there at all.
Santana Maria Lopez.
She forced herself to look away from the audience on the football field. Holding her head up and managing a superior smile, she crossed the stage. Principal Figgins handed her the diploma and shook her hand, and there was a smattering of applause and cheers from the members of New Directions, the only people who even bothered to pretend they cared about her. The rest of the vast crowd was already bored and waiting for the next person they recognized.
She kept the strained smile, because she wouldn't dream of letting anyone see she was upset. On the top of the steps leading down from the other side of the stage, she paused to check one more time. Maybe she just hadn't spotted them yet.
And that was when she saw Brittany, standing in the aisle, watching her.
In the most redundant of clichés, she felt as if her heart actually skipped a beat. She hadn't expected her to be here at all. Because in the end, Brittany hadn't gotten the required credits to graduate. She'd said, just this morning, that she wasn't coming to the ceremony. It was too hard to watch everyone move ahead without her.
Santana forced herself to continue down the steps as the name after hers was called. She moved toward the seating area for graduates, but instead of sliding into her row, she continued on toward Brittany, ignoring the stares.
"You changed your mind," she said.
"Yeah." Brittany smiled a little and looked down, sheepish. "I wanted to be here for you. And… I brought you something."
Santana watched as she produced a simple rose corsage. She swallowed hard.
"It's kind of small for a headband," Brittany went on. "But I thought you could wear it on your wrist."
She smiled and bit her lip, nodding. "Good idea."
Brittany slid the corsage over her hand. They were now the center of a small cluster of interest. Somebody took a picture, and Santana thought about grabbing the camera to destroy it, but decided not to. Let them look.
"It's beautiful," she said, tears stinging her eyes. She turned her wrist from side to side to display it. They stared at each other, time seeming to stop. Did Brittany have any idea what this meant to her?
"Sit down!" hissed the chemistry teacher, leaning toward them from her aisle.
"How about you sit down, Saddlebags," Santana told her, irritated by the interruption. "Or I'll tell everyone about the lipo my dad did on your thighs last week."
The woman fell back in her seat, stunned and intimidated.
"I'd better go," Brittany said.
"Wait." Santana took a deep breath. And before she could stop herself or talk herself out of it, she reached up and kissed her, cupping her face in her hands. The rose brushed against her cheek. Brittany, surprised at first, kissed her back. There were a few gasps from the people seated nearby, but they ignored them. It was getting easier.
She lowered herself back onto the ground from her tiptoes, watching Brittany smile down at her. Her expression was both touched and proud. That was all that mattered. It didn't matter anymore what anyone else thought.
"Come and sit with me," Santana told her, not wanting to let her go.
She seemed hesitant. "I don't want to get you in trouble."
"I've already got my diploma. What are they gonna do?"
Seeing the logic in this, Brittany said, "Okay."
Santana pulled her over to the aisle she was supposed to be seated in, and they worked their way down the row past the other kids in caps and gowns in the J and K section. Mercedes grinned at them as they passed. In the L section, she gave a pointed look to the band geek in the seat next to hers, and though he seemed to consider protesting, he thought better of it and moved down without a word.
She slid into her folding chair and tugged Brittany down beside her. They smiled at each other again.
Then, at the same time, their smiles faded a little as they both seemed to realize this was quite possibly the last time they would ever sit next to each other at McKinley High School. The very last time.
Santana held out her pinky. Brittany glanced down at it. Seeming to blink back tears, she held out her own. They linked them, squeezed them tight, and then regretfully turned their attention back to the stage.


text:
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text: Liberated Energy, Inc. (OTCQB: LIBE) has been established to bring affordable alternative energy to the marketplace. Currently, the Company has patents pending for a ridgeline roof wind device, and the Guard Lite. The Company is also looking at other alternative energy products that it hopes to seek patents on and commercialize.


text:
An awesome tweak though. Installing it straight away.
Edit: works just like how nickhesson said. You do need to call up the mini player though (double-tap home). Otherwise a feature that should have been built into the iphone considering is it supposed to be a media player. Couldn't we have 3 little dedicated media buttons Mr Jobs?
Cool, I'll get it!
Wow.. at first I thought you were advertising those gloves- which might be the gayest things I've ever seen..
But anyways, the app looks cool!
So do you need to load this first every time you listen to music?
Any chance it could be adapted to control Pandora Radio? I often can't rate a song because I'm busy riding my motorcycle and I can't take my hands off the wheel until after the song has finished and the opportunity gone (the next stop). Also, it's be pretty cool if an app could change your lock-screen wallpaper to show the album art Pandora fetches to make it function a little more like selections played from the iPod library. Instead, you end up having no idea what's playing unless you disable auto-sleep and screen dimming!
I would say that tapping it up twice for thumbs up, down twice for skip, and down thrice or down thrice and hold for thumbs down would be best (wouldn't want to accidentally thumb something down just to skip it). Also, AVRCP can't control Play/Pause in Pandora Radio, so the power button method would be greatly appreciated for any A2DP users.
doesnt work when the phone is completly in sleep mode. You have to activate the ipod on the lockscreen to work =P
thought this would be usefull for my bike so i can change it when its in my pocket. I couldnt get it to pause either
Worth checking out at least, even if you can't do any ratings with it.
so what if you want to turn down or up your music with this installed, you would change to the next song right?
Correct me if I'm wrong guys but hasn't something like this been around for a long time now? I have been using "Volume Media Settings" from Cydia and it seems like this GlovePod is the same thing? Anyway, stuff like this is very handy regardless, I've been using VMS every time I'm in the car. Good times.
edit - wait I'm seeing the benefits now, with this it's activated with the home key, where as VMS would still needs some fingers to activate the toggles. Got it, my bad
there has been a app like this out there for a year. called "Volume MC"
i have had this for forever. not new news


text:
Helpless Bouncer
11 pages
807 favorites
FUKE on September 19, 2011
Massive insertion is massive. A very short chapter by Zucchini in the Comic Unreal Anthology Ishukan Maniacs Vol. 1.
Comments on Helpless Bouncer
BLOWN78 (Mon Sep 19, 2011, 5:35 pm) +135 points
semperprimus (Mon Sep 19, 2011, 6:56 pm) +39 points
That thing come to my house I kill it
darkblack (Mon Sep 19, 2011, 6:59 pm) +27 points
Damn, look a that sumnbitch go! He Haulin' Ass!
Tyranosaurus_Secks (Mon Sep 19, 2011, 8:02 pm) +19 points
That rat lookin thang just got ATE!
Pedrodeperv (Sat Aug 11, 2012, 11:25 am) -6 points
Uh, sorry to say but that thing come to your house it kill you. And then it will fuck your female loved ones senseless right over your dead corpse and then use your bones as nesting for it's children which will most likely feed on your remains when they are born, and when they're done with that they'll probably then go to the very thing that brought them into this world, your female loved ones, and eat them as well. Yeah, like BLOWN said, DAMN NATURE YOU SCARY.
Loner (Mon Sep 19, 2011, 10:41 pm) +20 points
sex with a griffin...................Peter Griffin *peters laugh* ehehehehehe
xkawaiistrawberryx (Tue Sep 20, 2011, 1:23 am) +6 points
Mr. FuZaK'e (Wed Sep 21, 2011, 3:35 am) +4 points
you sir have made my day with a good laugh enjoy
MUCLUCK (Tue Sep 20, 2011, 3:21 pm) +3 points
she wont be able to walk that off
Rito Ayasaki (Mon Sep 19, 2011, 10:22 pm) +3 points
That was... Disturbing...
clairefarron198 (Sun Jul 29, 2012, 12:00 am) +1 points
........thats only in Japan...gotta love 'em all
Shadow-Espeon (Sun Oct 9, 2011, 4:11 pm) +2 points
...And there's Terry.
fenrirblade (Sat May 26, 2012, 4:10 am) +1 points
in more ways than on because i swear that things dick shank between pages 5 + 6
chibijesus (Sat Aug 4, 2012, 4:42 am) +1 points
Damn the mother fuckur fly fast you see that shit
geministar (Mon Sep 24, 2012, 2:34 pm) +1 points
So thats how harpies were born!!!
Pedrodeperv (Sat Aug 11, 2012, 11:26 am) +1 points
Now this would have been somewhat funny if they had made it like some sorta nature planet show.
Aksurtep (Mon Sep 19, 2011, 5:31 pm) +22 points
I can't believe I even took my dick out... my boner died after reading this. T_T
Dr._Strangelove (Tue Sep 20, 2011, 9:45 pm) +4 points
my boner died because it was jelly of the size of the depicted boner..... :-( FOREVER A BONE
kris916 (Mon Sep 19, 2011, 6:10 pm) +1 points
mine to i mean wtf was that
Janos (Tue Sep 20, 2011, 1:38 am) +5 points
I... I liked it... *hands in face and sobs*
DarkerInsight (Mon Sep 19, 2011, 8:25 pm) +1 points
This is just plain . . . . ugh, whatever boner I had disappeared as well. This was wrong on many levels.
Maeve (Tue Sep 20, 2011, 12:10 am) +1 points
This sounds like a challenge my body is ready for...
dragonsheart967 (Tue Sep 20, 2011, 3:05 am) +7 points
I just took your challenge and beat it.
sekireialpha (Wed Sep 21, 2011, 4:28 pm) +1 points
dragonsheart967 you are one sick fuck
SUPERHELL (Fri Jan 17, 2014, 3:40 am) +1 points
well crazy go end
mesumguy (Thu Nov 21, 2013, 12:26 pm) +1 points
WTF did I read??
CreamandPeachesCutie (Thu Aug 8, 2013, 1:40 am) +1 points
Damn, when I saw the size of that dick, my vagina started hurt
Jester's Tears (Thu Jul 4, 2013, 9:05 pm) +1 points
You can say, she got GRIF-OWNED...
(Yeah that joke was pretty terrible.)
(Yeah that joke was pretty terrible.)
datsikboyz (Tue Apr 30, 2013, 4:32 am) +1 points
OMG 666 Favorites at this time!
love can be scary as shit
there are no barriers when love is involved
Mura_kuroneko (Mon Nov 12, 2012, 5:40 am) +1 points
i some how really like this one.....hehe ya
Anime Seeker (Fri Sep 21, 2012, 9:54 am) +1 points
Doesn't suit griffin at all....
thehman (Thu Sep 20, 2012, 12:57 pm) +1 points
And' that's how Peter Griffon was born
zaberfang07 (Fri Aug 3, 2012, 10:24 pm) +1 points
That is one *Puts on Sunglasses* One Angry Bird...XD
vampyz3 (Tue Jul 31, 2012, 1:02 am) +1 points
Puh-leeze! First, she didn't even hold the Kukri right. Second, the reason she got captured is cuz she didn't have 2 therefore not having the ability to kill everyone. And third, DAMN NATURE, YOU SCARY!
crazdasian (Sun Jul 29, 2012, 2:32 am) +1 points
raptarion (Sun May 20, 2012, 12:52 am) +1 points
Is she made of rubber? You are NOT supposed to stretch that way.
Fortport (Mon Dec 19, 2011, 6:52 am) +1 points
I thought birds were asexual? . . . Derp.
theywere27 (Fri Dec 16, 2011, 10:18 am) +1 points
ok im pretty sure that really would break her in half
CaMmiCaMmi (Wed Dec 14, 2011, 8:02 pm) +2 points
That is... hot :P i wanna see a part two, maybe the chick raising the babies and disturbingly has sex with her new Griffin hubby every night!
misaseh098 (Sat Nov 19, 2011, 2:51 pm) +1 points
and that, people, is how harpies originated...
Shadowdamage (Tue Nov 1, 2011, 11:36 am) +1 points
Wouldn't the tag be considered "Monster" as well.
dajlinski (Sun Oct 23, 2011, 11:52 am) +1 points
i bet all of you looked up tags for this one...
Huckebein009 (Sat Oct 8, 2011, 10:08 pm) +1 points
Ooohhhh creepy
final cross 13 (Sun Oct 2, 2011, 12:29 am) +1 points
i'm surprised i didnt split her in half and the eggs...wow
hokova (Wed Sep 28, 2011, 1:53 pm) +1 points
...Am I weird when I read this all over again even though my chin dropped to knees the first time?
awesome5 (Mon Sep 26, 2011, 5:23 pm) +1 points
dam look at that son bitch go he halling ass
LarsonL (Sun Sep 25, 2011, 6:23 am) +1 points
Wtf I just read . .
clarac (Fri Sep 23, 2011, 11:40 am) +2 points
Scientifically speaking, this manage is flawed.
Humans are mammals and can't lay eggs even if they tried.
Then again manga is always outlandish in one way or another.
Humans are mammals and can't lay eggs even if they tried.
Then again manga is always outlandish in one way or another.
TheProdigy (Mon May 14, 2012, 5:10 pm) +1 points
Anything is possible in the world of Hentai.
theguyinthecorner (Wed Sep 21, 2011, 11:47 pm) +1 points
....it was okay....i thought he killed her in one stroke. im a fantasy fan so i was able to get over the fact his dick basically crushed all her organs and destroyed (literally) every pary of pussy. im not dissing it im just wondering what up with this fad in forced tags where the guy dick is so large it puls up th stomach. i once read one where the was long and wide enough to go down the girls throat to her stomach and cum directly inside. not a child though (different manga) the one im talking about is a teenager girl. kind of made lose a boner for 5 days and my libido is usually in overdrive. didnt mean to rant just confused. by the way i know its just a manga which is y im not upset just confused.
INSANE+RAGE (Wed Sep 21, 2011, 11:08 pm) +1 points
this is a perfect moment for this!
scalhoun (Wed Sep 21, 2011, 10:54 pm) +2 points
I kind wanna see more. Giggity
Godtracks (Wed Sep 21, 2011, 5:48 pm) +1 points
yes i love this type of comic ,i cum on it
View More


text:
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News from WTOP
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Mobile Phones threatened
The chief scientist with Berlin's Security Research Labs, revealed recently that he led a research team at the German firm that figured out a way to remotely gain control of and also clone some mobile SIM cards. Karsten Nohl, a well-known security expert said mobile carriers have quickly protected customers from that security bug that he revealed 10 days ago and that he estimated had put more than 500 million phones at risk of cyber-attacks.


text:
This past June, America watched as Phillip Garrido—the man who'd kidnapped California preteen Jaycee Dugard, raped her and became the father of her children—was sentenced to 431 years to life in prison. More details of Dugard's harrowing time trapped in Garrido's squalid backyard compound are sure to be revealed in her memoir this summer, but as troubling as her story is, we've all taken some comfort in the belief that a case like hers happens only once in a lifetime.
If only it were so.
Kristen and Will Stillman's story hasn't made national headlines or magazine covers, partly because, while Dugard's parents searched frantically and vocally for her, no one was looking for the Stillman twins. With no family and no place to run to, they could rely only on each other to withstand more than a decade of abuse and torture.
Theirs is a story of sibling love and survival. But it also raises tough questions for the rest of us: How could this happen to children living in plain sight? To a boy and a girl who were going to school? And how do you even begin to tell such a story? Perhaps in the words that Kristen, now 23, etched, cut or tattooed onto her body as cries for help that nobody seemed to notice, starting with the simple question:
(scar Kristen dug into her left thigh with pencil at age 11)
KRISTEN: We were eight and had gotten kicked out of our fourth shelter. Karen [the twins' mom] was always lying in bed or just not around. Maybe she was doing drugs—I don't know.
WILL: We were walking in a pretty nice neighborhood, and Karen knocked on the door of a white house with blue trim. It looked OK, at least on the outside.
KRISTEN: She told us to wait while she went in. When she came back, she said, "You can stay here." We met Eric, a big guy with a ponytail; his wife, Linda; and their daughter. After that, we saw Karen only a few more times. Basically she dumped us there. But that day I just figured, Hey, there are other kids here. I'm sure there's food.
WILL: For the first couple of months, it wasn't that bad. It was just another place with lots of people, like everywhere we'd been. Eric was clearly in charge.
KRISTEN: I'd always wanted a sister, and their daughter—she was around 12—and I were friends in the beginning. They also had a son, Patrick, who was nine, and a two-year-old boy. The house was really small. Linda's mom and dad lived there too, and her brother, and Eric's dad—everyone called him Apple. I remember Linda's mom, who moved out later, cutting my hair and telling me stories of being a nurse in the war. But things started to change a month into fourth grade, when Eric made me stand in the corner with my hands in the air for, like, 12 hours. Will, too.


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Medical Policy
|Vagus Nerve Stimulation
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Vagus nerve stimulation (VNS) involves the use of a pulse generator, similar to a pacemaker, that is surgically implanted under the skin of the chest with an electrical lead (wire) connected from the generator to the left vagus nerve. Electrical signals are sent from the battery-powered generator to the vagus nerve via the lead. These signals are in turn sent to the brain.
This document addresses the use of an implantable VNS device and the electronic analysis of the implanted neurostimulator pulse generator system for the treatment of medically and surgically refractory seizures associated with intractable epilepsy and as a treatment of other conditions.
|Position Statement
Medically Necessary:
Implantation of a vagus nerve stimulation device is considered medically necessary in an individual with medically and surgically refractory seizures as evidenced by:
Electronic analysis of an implanted neurostimulator pulse generator system for vagus nerve stimulation is considered medically necessary when the implantation occurred because the above criteria were met.
Investigational and Not Medically Necessary:
Implantation of a vagus nerve stimulation device is considered investigational and not medically necessary as a treatment for all other conditions, including, but not limited to:
Electronic analysis of an implanted neurostimulator pulse generator system for vagus nerve stimulation is considered investigational and not medically necessary when the medically necessary criteria for device implantation are not met.
VNS as Treatment of Medically and Surgically Refractory Seizures
Published evidence from well-designed multimember trials involving over 300 participants with long-term follow-up demonstrates the use of VNS as an adjunct to optimal use of antiepileptic drugs in the treatment of medically refractory individuals with at least six partial onset seizures per month reduces seizure frequency by approximately 25% after three months of treatment (Morris, 1999; Murphy, 1999). In individuals who achieve an initial reduction in seizure frequency, the beneficial treatment effect appears to be maintained and may increase with time. Adverse effects are mild and consist primarily of hoarseness or voice change during periods of stimulation. With increasing experience with VNS, candidate selection is not based on the number of seizures alone, but on the presence of seizures that are refractory to medical therapy, either in terms of persistence of seizures, or due to intolerable side effects of drug therapy (Benbadis, 2000; Fisher, 1999). Additionally, the original FDA approval limited the use of VNS to individuals over the age of 12 years. Initial studies reported results that support the safety of the device in children with refractory seizures (Patwardhan, 2000; Salinsky, 1996). The long-term efficacy and safety of VNS therapy in the pediatric population was further reported in several moderately large retrospective case series (Alexopoulos, 2006; Benifla, 2006; De Herdt, 2007). Tecoma and Iragui (2006) observed that since approval of VNS for partial seizures, a number of case series including individuals with generalized seizures have been published. These series report seizure reduction rates similar or greater than those reported in partial epilepsy, and note that "this body of evidence suggests that VNS has broad antiepileptic efficacy." The authors suggest that these results may be particularly important since resective epilepsy surgery is generally not feasible in these individuals. You and colleagues (2007) reported that 15 of 28 children (53.6%) with refractory seizures showed a greater than 50% reduction in seizure frequency, nine children (32%) had a greater than 75% reduction, and there were no significant differences when groups were compared by seizure type or etiology. Tecoma and Iragui (2006) cite a multicenter retrospective analysis of 50 children with Lennox-Gastaut syndrome (LGS) treated with VNS. Median seizure reduction at six months was 88% for tonic seizures and 81% for atypical absences. You and colleagues (2008) compared VNS and total corpus callosotomy for LGS. Of the 14 individuals who underwent a corpus callosotomy, nine individuals (64%) had a greater than 50% reduction in seizure frequency and five individuals (36%) had a greater than 75% reduction. Of the 10 individuals who underwent VNS implantation, seven individuals (70%) had a greater than 50% reduction in seizure frequency and two individuals (20%) had a greater than 75% reduction.
An observational study by Kostov and colleagues (2009) investigated the utility of long-term VNS therapy in 30 individuals with LGS (median observation time was 52 months). The authors reported a median reduction in the total number of seizures and different seizure types was 60.6%. Seizure reduction of 61% was also reported in a case series of 12 individuals with drug-resistant idiopathic generalized epilepsy (Kostov, 2007). Based on these data, the conclusion can be drawn that VNS is an effective treatment for refractory seizures other than partial epilepsy.
Additional retrospective case series measuring the long term effects of VNS for medically and surgically refractory seizures in adults and the pediatric population have subsequently been published in the peer-reviewed literature. Significant reductions in seizure frequency with possible cumulative effect have been reported along with a reduction in surgical complications and untoward side effects with chronic VNS therapy (Coykendall, 2010; Elliott, 2011a; Elliott, 2011b; Elliott, 2011c; Ghaemi, 2010; Kabir, 2009; Siddiqui, 2010; Vale, 2011). Englot and colleagues (2011) performed the first meta-analysis of VNS efficacy in epilepsy, identifying 74 clinical studies with 3321 participants with intractable epilepsy. These studies included three blinded, randomized controlled trials (Class I evidence); two nonblinded, randomized controlled trials (Class II evidence); 10 prospective studies (Class III evidence); and numerous retrospective studies. After VNS implantation, seizure frequency was reduced by an average of 45%, with a 36% reduction in seizures at 3-12 months after surgery and a 51% reduction after greater than one year of therapy. At the last follow-up, seizures were reduced by 50% or more in approximately 50% of the individuals, and VNS predicted an equal to or greater than 50% reduction in seizures (main effects, odds ratio of 1.83; 95% confidence interval 1.80-1.86). Individuals with generalized epilepsy and children benefited significantly from VNS despite their exclusion from initial approval of the device. The authors concluded that VNS is an effective and relatively safe adjunctive therapy in individuals with medically refractory epilepsy not amenable to resection. However, it is important to recognize that complete seizure freedom is rarely achieved using VNS and that a quarter of individuals do not receive any benefit from therapy.
VNS as Treatment of Refractory Depression
Interest in the application of VNS for treatment of refractory depression is related to reports of improvement in depressed mood among individuals with epilepsy undergoing VNS. In 2005, the vagus nerve stimulator received U.S. Food and Drug Administration (FDA) approval for this indication. The data presented to the FDA by the manufacturer of the VNS Therapy® (Cyberonics, Inc., Houston, TX, U.S.A.) consisted of a case series of 60 individuals receiving VNS (Study D-01), a short-term (3-month) randomized sham-controlled clinical trial of 221 individuals (Study D-02), and an observational study comparing 205 individuals on VNS therapy to 124 individuals receiving ongoing treatment for depression (Study D-04) (George, 2005; Rush, 2000). Individuals who responded to sham treatment in the short-term randomized, controlled trial (approximately 10%) were excluded from the long-term observational study.
The primary efficacy outcome of interest is the relief of depression symptoms. This outcome may be assessed by any one of many different depression symptom rating scales. A 50% reduction from baseline score is considered to be a reasonable measure of treatment response. An improvement in depression symptoms may allow reduction of pharmacologic therapy for depression, with a reduction in side effects related to that form of treatment. In the studies evaluating VNS therapy, the four most common instruments used were the Hamilton Rating Scale for Depression (HAMD), Clinical Global Impression, Montgomery and Åsberg Depression Rating Scale (MADRS), and the Inventory of Depressive Symptomatology Self-Related (IDS-SR).
The case series data reported rates of improvement, as measured by a 50% improvement in depression score of 31% at 10 weeks to greater than 40% at one to two years. This appeared to stabilize out to two years, but there were substantial losses to follow-up (n=42 at two years versus original sample of 59) (Marangell, 2002; Rush, 2000; Sackeim, 2001). Natural history, placebo effects, and the expectations of the individual and their medical practitioner make it difficult to infer efficacy from this case series data.
The D-02 randomized trial (Rush, 2000; Rush, 2005a) comparing VNS therapy to a sham control, (implanted but inactivated VNS), showed a non-statistically significant result for the principal outcome at three months. Fifteen percent of VNS subjects responded, versus 10% of control subjects (p=0.31). The IDS-SR was considered a secondary outcome, showing a difference that was statistically significant in favor of VNS (17.4% versus 7.5%, p=0.04). All other outcomes assessed in the trial did not show statistically significant differences between groups.
The observational study comparing subjects participating in the randomized clinical trial and a separately recruited control group (D-04 vs. D-02) evaluated VNS therapy out to one year, showing a statistically significant difference in the rate of change of depression score (p<0.001) (George 2005; Rush, 2000). This study was conceived after the results of the randomized clinical trial were known. The outcomes of this study, however, may have been confounded by issues such as unmeasured differences between subjects, nonconcurrent controls, differences in sites of care between subjects with VNS therapy and controls, and differences on concomitant therapy changes. Analyses performed on subsets of subjects cared for in the same sites and censoring observations after treatment changes, generally showed diminished differences in apparent treatment effectiveness of VNS with almost no statistically significant differences. Considering these concerns about the quality of the observational data, these results lack strong evidence to support the effectiveness of VNS therapy as a treatment for refractory depression.
Nahas and colleagues (2005) evaluated the safety and effectiveness of VNS in an acute phase pilot study of 59 individuals with treatment-resistant major depressive episode (MDE). They examined the effects of adjunctive VNS over 24 months in this adult population. Adults treated in the outpatient setting with chronic or recurrent major depressive disorder or bipolar (I or II) disorder and experiencing a treatment-resistant, non-psychotic MDE (DSM-IV criteria) received two years of VNS. Changes in psychotropic medications and VNS stimulus parameters were allowed only after the first three months. Response was defined as greater than or equal to 50% reduction from the baseline 28-item Hamilton Rating Scale for Depression (HAMD-28) total score, and remission was defined as a HAMD-28 score less than or equal to 10. Based on last observation carried forward analyses, HAMD-28 response rates were 31% (18/59) after three months, 44% (26/59) after one year, and 42% (25/59) after two years of adjunctive VNS. Remission rates were 15% (9/59) at three months, 27% (16/59) at one year, and 22% (13/59) at two years. By two years, two deaths (unrelated to VNS) had occurred, four participants had withdrawn from the study, and 81% (48/59) were still receiving VNS. Longer-term VNS was generally well tolerated, however, at 24 months, the accumulated serious adverse events affected 42% of the individuals. These investigators concluded that their findings suggest that individuals with chronic or recurrent, treatment-resistant depression (TRD) may show long-term benefit when treated with VNS. However, the number of responders and the degree of their improvement waxed and waned over the two year study. Since there was no control group, it is difficult to determine if this was due to the VNS or the natural course of chronic depression. There was no information on whether any subjects failed to respond to either electroconvulsive therapy (ECT) or details about antidepressant augmentation strategies utilized prior to being accepted into this study.
A review of the literature indicates there continues to be a lack of randomized controlled studies conducted in the United States (U.S.) that report clinical outcomes on any new or different individuals than those reported on in prior studies. These studies involve the same data that was reanalyzed from prior studies and continued to demonstrate a lack of evidence of efficacy beyond that provided by the original data. In summary, the available evidence is insufficient to permit conclusions regarding the effect of VNS therapy on health outcomes or its effect compared with alternative therapies. Further randomized controlled trials are needed to address the complex and unresolved issues of dose, sham control, participant blinding, and length of treatment phase to demonstrate the efficacy of VNS as a treatment of depression (George, 2007).
An open-label, uncontrolled, unblinded study of VNS therapy, in addition to concomitant treatment with antidepressant medications (stable for four weeks prior to study entry, during the recovery period and the acute study phase), enrolled individuals with TRD or bipolar I or II disorder at nine European sites from 2001 to 2005 (D03) (Schlaepfer, 2008). This study was reported as being partially sponsored by the VNS device manufacturer. The study protocol was similar to the D01 study conducted in the U.S., except that: (1) the study inclusion required a score equal to or greater than 20 on the HAMD-24 scale in the D03 study, as opposed to equal to or greater than 20 on the HAMD-28 scale in the D01 study, (2) the maximum age at entry was 80 in the D03 study and 70 in the D01 study, and (3) the number of failed adequate medication trials was equal to or greater than two but less than six in the D03 study versus equal to or greater than two in the D01 study. During the long-term follow-up period, adjustments in stimulation parameters and medications were permitted. Of the 74 participants implanted with the device, four withdrew during the acute study period. Seven participants dropped out during the first-year long-term study period, five due to adverse events or lack of efficacy, and two participants committed suicide. Primary outcomes were reported as a reduction in the severity of depression as measured by the HAMD-24, but HAMD-28 was assessed and used for comparison of results to the D01 study. The baseline HAMD-28 score averaged 34. After three months of VNS, response rates (greater than or equal to 50% reduction in baseline scores) reached 37% and remission rates (HAMD-28 score less than 10) 17%. Response rates increased to 53% after one year of VNS, and remission rates reached 33%. Response was defined as sustained if no relapse occurred during the first year of VNS after response onset; 44% of participants met these criteria. Median time to response was nine months. Most frequent side-effects were voice alteration (63% at three months of stimulation) and coughing (23%). Comparing results of this study to the D01 study results, the investigators reported a decrease in severity of depression after three, six, nine, and 12 months compared to baseline HAMD-28 score, reaching significance in both samples over time, with higher efficacy in the D03 study compared to the D01 study. This was attributed to the lower measures of baseline depression in the D01 study. The investigators, however, reported "a major shortcoming" of this study, as in the U.S. D01 study, was that effectiveness was not assessed in a sham controlled design, "limiting interpretations on clinical utility." In addition, the authors suggest in future trials of VNS for depression, "it might therefore be valuable to study the specific characteristics of personality of a patient population with treatment resistance interested in this procedure (VNS) to judge whether personality features contribute differentially to treatment effects" (Schlaepfer, 2008).
Cristancho and colleagues (2011) followed participants with major depressive disorder (n=10) and with bipolar disorder (n=5) at 6 and 12 months post-VNS implantation between November 2005 and August 2006. At the 12 month follow-up, 4 of 15 participants responded and 1 of 15 participants remitted according to the principal response criteria. These outcomes are comparable to those observed in previous VNS efficacy studies and with a similar side effect profile, however, the small sample size, lack of a comparison group, and short-term outcome measurements limit this study in drawing conclusions concerning the net health benefit of VNS for this group of individuals.
Fitzgerald and Daskalakis stated in a 2008 review that "given the invasive nature of vagal nerve stimulation and potential side effects, further research is urgently required." A guideline statement from the Canadian Network for Mood and Anxiety Treatments included a review of the literature on VNS for depression and concluded that there is a lack of substantive evidence for short-term and long-term efficacy in acute severe depression, and that the appropriate place of VNS remains to be determined (Kennedy, 2009). A small open label, longitudinal cohort study by Bajbouj and colleagues (2010) reported data after following participants for two years. The results indicated that 53.1% (26/49) of individuals met the treatment response criteria (greater or equal to a 50% reduction in the HAMD-28 scores from baseline) and 38.9% (19/49) fulfilled the remission criteria (HAMD-28 scores less than or equal to 10) while on VNS. These results are limited in demonstrating improved health outcomes due to the small study population and lack of a comparison group.
A workgroup of the American Psychiatric Association has published the third edition of the Practice Guideline for the Treatment of Patients with Major Depressive Disorder. According to the guideline, "Vagus nerve stimulation is approved for use in patients with treatment-resistant depression on the basis of its potential benefit with long-term treatment. There is no indication for the use of VNS in acute phase treatment of depression, as data showed no evidence for acute efficacy" (Rush, 2005a; Sackeim, 2001). For individuals "whose symptoms have not responded adequately to medication, ECT remains the most effective form of therapy and should be considered." However, for those individuals with TRD, "Vagus nerve stimulation (VNS) may be an additional option for individuals who have not responded to at least four adequate trials of antidepressant treatment, including ECT" (Level of Clinical Confidence III: May be recommended on the basis of individual circumstance) (Gelenberg/APA, 2010).
An Agency for Healthcare Research and Quality's (AHRQ) comparative effectiveness review (Gaynes, 2011) summarized the evidence concerning the effectiveness of four treatments in the clinical management of TRD, including ECT, repetitive transcranial magnetic stimulation (rTMS), VNS, and cognitive behavioral therapy (CBT) or interpersonal psychotherapy (IPT). The following is a summary of the findings on the efficacy and safety of VNS for adult TRD:
The review concluded that many clinical questions about efficacy and effectiveness remain unanswered. Comparative clinical research on nonpharmacologic interventions in a TRD population is in its infancy. Comparison of any of the potential interventions in the treatment of TRD, nonpharmacologic or otherwise, is hampered by variable definitions of TRD, heterogeneity of study participants, and lack of clinically meaningful interpretation of pertinent outcome measures as relevant studies did not assess both response and remission rates.
VNS as Treatment of Other Conditions
Unintended weight loss has been observed in participants in studies of VNS prompting interest in use of the technology to prevent or treat obesity. Bodenlos and colleagues (2007) investigated whether VNS might affect food cravings in individuals with chronic TRD. Thirty-three participants were divided into three groups; 11 subjects receiving VNS for depression, 11 subjects with depression but not receiving VNS, and 11 healthy controls. Most participants (42%) had a BMI in the normal range. Participants viewed food images on a computer in random order and then a second time in the same order, and were asked after each viewing how much they would like to eat each food if it were available and how well they would be able to resist tasting each one. VNS devices were turned on for one viewing and off for the other. The depression VNS group had greater differences in food cravings between viewings in the sweet food category than the other two groups. No significant differences between groups were found for foods in proteins and vegetables/fruits categories. A significant proportion of the variability in VNS–related changes in cravings for sweet foods was attributed to clinical VNS device settings, depression scores and BMI. A number of limitations in the study prevent drawing conclusions about the impact of VNS on eating behavior including small study size, selection and lack of randomization, heterogeneity of groups with respect to depression, BMI, and age. Comorbidities including anxiety and medical conditions and drugs that might influence food intake and cravings were not considered. Large, well-designed and executed controlled studies are needed to evaluate the impact of VNS on eating behavior and obesity.
A possible role of VNS therapy to affect pain perception was evaluated by Mauskop (2005) in five individuals with severe, refractory chronic cluster and migraine headaches. Cecchini and colleagues (2009) evaluated VNS in a small study of four individuals suffering from daily headaches and chronic migraine. These studies are too small to draw conclusions on the effects of VNS for the treatment of headache. Mathew (2009) reviewed the current and future treatments for chronic migraine headaches, stating that clinical trials indicate combination therapy may have a place in treating refractory chronic migraine, yet, well-controlled multicenter trials are needed.
In an open-label, phase II trial of VNS therapy utilizing the CardioFit® device (BioControl Medical, Yehud, Israel - New Hope, Minnesota) for chronic heart failure, De Ferrari and colleagues (2011) reported improvements in New York Heart Association (NYHA) class II-IV individuals (n=32) in measures of quality of life, six-minute walk test, and left ventricular ejection fraction (from 22±7 to 29±8%, p=0.003). An international multicenter randomized clinical trial (INOVATE-HF) assessing the safety and efficacy of the CardioFit System in symptomatic individuals with heart failure is currently recruiting participants (Hauptman, 2012). To date, the CardioFit device has not received FDA clearance for VNS therapy or any other indication.
VNS therapy has been investigated as a treatment for essential tremor (Handforth, 2003), enhancing cognitive deficits in Alzheimer's disease (Merrill, 2006), anxiety disorders, and bulimia. Other studies explore the potential use of VNS in the treatment of autism (Danielsson, 2008), fibromylagia (Lange, 2011), morbid/resistant obesity (Camilleri, 2008; Sarr, 2012), addictions, sleep disorders, narcolepsy, coma, and memory and learning deficits (Ansari, 2007). A search of the clinicaltrials.gov database identified studies in various phases investigating the effects of implantable VNS on cluster headaches, Crohn's disease, myocardial function in heart failure, enteroendocrine secretion and glucose metabolism in Type 2 diabetes-related obesity, rheumatoid arthritis, and recovery from minimally conscious or persistently vegetative states after traumatic brain injury (U.S. National Institutes of Health, 2013). To date, the FDA has not cleared the use of any type of implantable VNS device for these indications. Well-designed, randomized clinical trials with larger populations are needed to demonstrate the safety and efficacy of VNS therapy as a treatment for any of these conditions.
According to the Epilepsy Foundation (2013), epilepsy affects three million people in the U.S. and includes more than 300,000 children under the age of 15. More than 90,000 young people in this group have seizures that cannot be adequately treated. The National Institute of Neurological Disorders and Stroke (NINDS, 2013) reports that 20% of persons with epilepsy experience intractable seizures (seizures that do not respond to treatment).
The American Association of Neurological Surgeons (AANS, 2013) currently classifies seizures to include two basic categories: primary generalized seizures and focal seizures (previously referred to as partial seizures). Classifying the type of seizure is important in the selection of appropriate antiepileptic drug treatment. Despite advances in the medical and surgical treatment of epilepsy, 25% to 50% of individuals with epilepsy experience breakthrough seizures or suffer from debilitating adverse effects of antiepileptic drugs.
The VNS device is an implantable stimulator similar to a cardiac pacemaker. The surgery consists of implanting the pacemaker-like generator under the skin in the left chest area. A nerve stimulation electrode is tunneled under the skin to the lower neck where it is placed around the left cervical vagus nerve. The neurologist, using an external programmer sets or resets the stimulation parameters of the device to deliver preprogrammed intermittent electrical pulses to the vagus nerve, which then transmits that stimulation to the brain to create widespread antiepileptic effects. Additionally, when an individual senses a seizure coming on, he/she can activate the system to deliver an additional dose of stimulation by passing a magnet over the area of the chest where the device is implanted. The device is powered by a lithium thionyl chloride battery that must be replaced every 1.5-5 years depending on the stimulation parameters. Adverse effects of VNS therapy included voice alteration, headache, neck pain, and cough, which are known from prior experience with VNS therapy for seizures.
A VNS device was originally approved by the FDA for the treatment of refractory epilepsy. In April 1999, the Centers for Medicare and Medicaid Services (CMS) issued a national coverage determination (NCD 160.18, effective for services performed on or after July 1, 1999) for VNS as an effective treatment for medically refractory partial onset seizures when surgery is not recommended or has failed. At the same time, CMS determined that VNS was not medically reasonable and necessary for resistant depression. On July 15, 2005, the FDA granted premarket approval to Cyberonics, Inc. for their VNS Therapy System for the adjunctive long-term treatment of chronic or recurrent depression for individuals 18 years of age or older who are experiencing a major depressive episode and have not had an adequate response to four or more antidepressant treatments. CMS subsequently initiated a national coverage analysis in follow-up to a request to reconsider resistant depression as an additional indication for VNS (CMS, 2007). After a review of the evidence, CMS concluded in a national non-coverage determination (effective May 4, 2007) that VNS is not reasonable and necessary for individuals with TRD. Ongoing studies of VNS are documented on the clinicaltrials.gov database including a registry for individuals with treatment-resistant depression.
Focal seizure: A seizure that begins with an electrical discharge in a relatively small area (called the focus) of the brain; previously referred to as a partial or localization-related seizure. In most cases, the cause is unknown, but may be related to a brain infection, head injury, stroke, or a brain tumor.
Medically refractory seizures: Seizures that occur despite treatment with therapeutic levels of antiepileptic drugs or seizures that cannot be treated with therapeutic levels of antiepileptic drugs because of intolerable adverse side effects.
Refractory depression: A major depressive disorder that fails to demonstrate an adequate response to an adequate treatment trial of antidepressant medications (i.e. sufficient intensity of treatment for sufficient duration); also referred to as treatment-resistant depression (TRD). Potential factors contributing to apparent non-response include trial adequacy, individual compliance, differential diagnosis, and treatable comorbid conditions.
Vagus nerve: A nerve that controls both motor and sensory functions of the gastrointestinal tract, heart and larynx; also referred to as the 10th cranial nerve.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
When services may be Medically Necessary when specified as vagus nerve stimulator and criteria are met:
|Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array
|Percutaneous implantation of neurostimulator electrode array; cranial nerve
|Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator
|Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator
|Electronic analysis of implanted neurostimulator pulse generator system; complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing
|Generator, neurostimulator (implantable), nonrechargeable
|Implantable neurostimulator, pulse generator, any type
|Implantable neurostimulator electrode, each
|Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
|Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension
|ICD-9 Procedure
|[For dates of service prior to 10/01/2014]
|Implantation or replacement of peripheral neurostimulator
|ICD-9 Diagnosis
|[For dates of service prior to 10/01/2014]
|ICD-10 Procedure
|[For dates of service on or after 10/01/2014]
|Insertion of neurostimulator lead into cranial nerve, open approach
|Insertion of neurostimulator lead into cranial nerve, percutaneous approach
|Insertion of neurostimulator lead into cranial nerve, percutaneous endoscopic approach
|ICD-10 Diagnosis
|[For dates of service on or after 10/01/2014]
|Epilepsy and recurrent seizures
When services are Investigational and Not Medically Necessary:
For the procedure codes listed above when specified as vagus nerve stimulator when criteria are not met or for all other diagnoses (including but not limited to those listed below), or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.
|ICD-9 Diagnosis
|[For dates of service prior to 10/01/2014]
|All other diagnoses, including, but not limited to:
|Overweight and obesity
|Episodic mood disorders
|Depressive type psychosis
|Autistic disorder
|Bulimia nervosa
|Organic sleep disorders
|Alzheimer's disease
|Essential and other specified forms of tremor
|Cluster headaches
|Infantile cerebral palsy
|Cataplexy and narcolepsy
|Heart failure
|ICD-10 Diagnosis
|[For dates of service on or after 10/01/2014]
|All other diagnoses, including, but not limited to:
|Overweight and obesity
|Mood (affective) disorders
|Bulimia nervosa
|Autistic disorder
|Essential and other specified forms of tremor
|Alzheimer's disease
|Cluster headaches
|Organic sleep disorders
|Cerebral palsy
|Heart failure
When services are also Investigational and Not Medically Necessary:
|Vagus nerve blocking therapy (morbid obesity); laparoscopic implantation of neurostimulator electrode array, anterior and posterior vagal trunks adjacent to esophagogastric junction (EGJ), with implantation of pulse generator, includes programming
|Vagus nerve blocking therapy (morbid obesity); laparoscopic revision or replacement of vagal trunk neurostimulator electrode array, including connection to existing pulse generator
|Vagus nerve blocking therapy (morbid obesity); laparoscopic removal of vagal trunk neurostimulator electrode array and pulse generator
|Vagus nerve blocking therapy (morbid obesity); removal of pulse generator
|Vagus nerve blocking therapy (morbid obesity); replacement of pulse generator
|Vagus nerve blocking therapy (morbid obesity); neurostimulator pulse generator electronic analysis, includes reprogramming when performed
|ICD-9 Diagnosis
|[For dates of service prior to 10/01/2014]
|All diagnoses
|ICD-10 Diagnosis
|[For dates of service on or after 10/01/2014]
|All diagnoses
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Web Sites for Additional Information
VBLOC® Vagal Blocking Therapy
VNS Therapy
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
|Document History
|Updated Coding section with 01/01/2014 HCPCS changes.
|Medical Policy & Technology Assessment Committee (MPTAC) review. Added treatment of heart failure to the VNS investigational and not medically necessary indications and clarified electronic analysis statement. Updated Rationale, Background, Definitions, Coding, References, Web Sites for Additional Information, and Index sections.
|Updated Coding section with 01/01/2013 CPT changes.
|MPTAC review.
|Behavioral Health Subcommittee review. Updated Rationale, Background, References, and Web Sites for Additional Information.
|MPTAC review. Updated Rationale, References, and Web Sites for Additional Information.
|MPTAC review. Clarified statement for electronic analysis of an implanted VNS device, that it is medically necessary for monitoring of an appropriately implanted device. Updated the Rationale, Background, Definitions, References, Web Sites for Additional Information and Index. Updated Coding section to include 01/01/2011 CPT changes; removed 64573 deleted 12/31/2010.
|MPTAC review. Added medically necessary statement addressing analysis of an implanted neurostimulator pulse generator system for VNS when criteria are met. Clarified and expanded investigational and not medically necessary statements: added specific medical conditions and separate statement to address when analysis of an implanted neurostimulator pulse generator system for VNS is investigational and not medically necessary. Updated Description, Rationale, Background, and References. Updated Coding section with 01/01/2010 HCPCS changes.
|MPTAC review. Rationale, Definitions, and References updated.
|Updated Coding section with 10/01/2008 ICD-9 changes.
|MPTAC review. Clarified Position Statement. Rationale, Background, Coding and References updated. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary."
|MPTAC review. Background/Overview updated.
|MPTAC review. References updated. Coding update: removed HCPCS E0752, E0754, E0756 deleted 12/31/05.
|Updated Coding section with 01/01/2006 CPT/HCPCS changes
|MPTAC review.
|Added reference for Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD).
|MPTAC review.
|MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
|Pre-Merger Organizations
|Last Review Date
|Document Number
|Anthem, Inc.
|Vagus Nerve Stimulation Therapy
|WellPoint Health Networks, Inc.
|Vagus Nerve Stimulation


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Rock Hudson (November 17, 1925 October 2, 1985) was an American actor, famous for his rugged good looks. He was the first major American celebrity known to have died from AIDS (specifically, AIDS-related cancer of the lymph ... moreAdd to my favourites Get these quotes on a PDF
I'm notorious for giving a bad interview. I'm an actor and I can't help but feel I'm boring when I'm on as myself.


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When we arrived they said they didnt look at Hostelworld for the reservation, so our room was taken. After asking for our deposit back,all of a sudden they had a room?!which seemed to be the one we booked anyway.The room stunk of bleach,the light barely lit the room,the walls were paper thin so you hear everything,room didnt get cleaned,would definitely not stay here.
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Actress Zelda Rubinstein, best known for her role as Tangina in Tobe Hooper's classic "Poltergeist," died of natural causes on Wednesday. She was 76.
Have you longed to feel the rancid breath of a giant ape on your face as he leaps over your head to attack a rampaging Tyrannosaurus Rex? If so, you're in the luck. Filmmaker Peter Jackson has helped Universal Studios relaunch their "King Kong" theme park ride, which will open its doors this summer. Remember to pack your banana hammock.
The first trailer for Capcom's upcoming live-action adaptation of "Dead Rising" has appeared online. It's cheap, it's ugly, and it's extremely violent. In other words, I'm giddy with excitement.
Anchor Bay recently announced they have acquired the rights to Agnieszka Wojtowicz-Vosloo's "After Life," a new horror/thriller starring Christina Ricci, Justin Long, and Liam Neeson. When this thing will see the light of day is still anybody's guess.
What do 18 year-old female werewolves do for fun? For starters, they use pocket knives to severe the heads of lost dogs. Time permitting, they boil the skulls.
I'm no parent, but I'm pretty sure strapping your baby to the wall with duct tape isn't in the instruction manual. Neither is documenting the event with your digital camera.
When you're hanging out in the parking lot at the local mall, the last thing you expect is to be savagely attacked by a wandering cobra. Destro was not immediately available for comment.
1977 - Freddie Prinze commits suicide at the age of 23.
Underground gore fanatic and influential genre film critic Chas. Balun has passed away at the age of 61. He will be missed. And if you haven't read "Horror Holocaust," do so immediately.
Good news for those who still read books: W.W. Norton & Co will release an english language adapation of Ryu Murakami's "Audition" in June of 2010. The book, of course, was the foundation for the Takashi Miike movie of the same name.
Inexplicably excited about the upcoming remake of "The Wolfman?" To help fuel your wavering interest, Universal has launched the official website, which comes complete with a trailer and an assortment of time-wasting materials. Don't pretend like you've got something better to do.
Funeral Home Management 101: When you're preparing to cremate a corpse, you might want to make sure you're deep frying the right dead guy. People tend to get upset about things like that.
The next time you and your family are suffering from boredom, try lighting yourselves on fire in front of a video camera. You might get a TV show.
1984 - Rick Allen, drummer for Def Leppard, loses his arm in a car crash.
Avenged Sevenfold drummer James Owen Sullivan, also known as "The Rev", was found dead yesterday in his home, apparently of natural causes. The 28 year old musician was a founding member of the California based metalcore group, which was in the process of recording their fifth album. Avenged Sevenfold had also recently recorded a version of Pantera's "Walk" for a tribute album being assembled by Zakk Wylde.
Well, as I'm sure you've heard by now, Michael Jackson, the "King of Pop" passed away today after suffering a cardiac arrest at his home.
Based on reactions I'm witnessing on the various social networks I frequent, responses are decidedly lacking in nuance. Either people are acting as if a close personal relative has died, praising Jackson and ignoring his transgressions, or they're making crass jokes and focusing only on the bad things he's done. It seems to be that way with most things in life these days, and it's a shame.
This week we discuss alchemy, camera technology, a first time guest host joins the show, and we review "As Above, So Below".


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The Wii Mini is the new version of the Wii console, giving you motion gaming at a great entry level price and superb portability.
The Wii Mini is designed for pure Wii gaming. And with no online features to worry about, it's great for kids, families, and even to take away on holiday!
It comes packed with a red Wii Remote Plus controller & Nunchuk accessory. Plug it in and play!
Thanks to the motion sensor, fun and intuitive gameplay is enhanced by your own body movements will get the entire family up and off the couch for unforgettable gaming sessions.
The Wii Mini is compatible with the huge catalogue of Wii games, including top franchises from the likes of Mario and Zelda – perfect for catching up on some classic Wii titles!
Get your games collection off to a perfect start with Mario Party 8 featuring a great selection of mini games that are perfect for sharing.
Included in the box: Wii Mini Console, Wii Remote Plus Controller, Nunchuk Accessory, Sensor Bar, Wii Power Supply and Wii AV CableWII helpline: 0845 6050247.
Create your own customised workout routines or choose routines over 20, 30 or 40 routines to suit your fitness levels, target areas and time you have available.
The Balance Board also adds to the fun to keep you motivated, including activities like Skateboarding and Rhythm Kung Fu. Workouts combine the original Wii Fit activities and selections from 15 new balance games and 6 new strength training and yoga activities.
Just decide how long you want your workout to be or select an area for personal improvement, and Wii Fit Plus will suggest a number of diverse routines.
You can mix and match strength and yoga activities, with the seamless exercise flow make it easier than ever to maintain your daily workout routine.
Users might be asked to run an obstacle course across a series of platforms, zoom across a beach on a Segway Personal Transporter or flap your arms to help a hilarious chicken-suited character aim for targets.
The range of games and customisation options will make players ensure the time flies by as you get fit with a smile on your face. You can also see estimates of calories burned to keep you motivated. You can even weigh your dog or cat!
Age from 3 years.
Fans of the Disney Planes movie will love the acrobatic aerial action of this fun Nintendo Wii game version!
You can take on the role of Dusty the crop duster or many other characters from the film, including his arch-rival Ripslinger, as you take on a series of fun challenges.
Take on tasks such as restarting power stations by directing lightning from the clouds, launching fireworks for a display and shooting piles of coloured powder for the Indian festival of Diwali or simply explore the impressive landscapes in Free Flight mode.
Disney Planes is sure to provide hours of fun for younger gamers.
Age from 7 years.
Mario Kart Wii allows you to enjoy the blood-pumping kart-racing game that is loved by Nintendo fans worldwide. Use a variety of fun items that can turn the tide of your race; from the Green Shell to the Mega Mushroom! You can use the Wii Wheel with Wii Remote to race on 32 new for Wii or classic action-packed courses, the Wii Wheel can also be bought separately. Race or enjoy the Battle Mode in single or multi-player and play with up to 4 players in split-screen.
Age from 3 years.
Just Dance 2015 has the most interactive features and hottest track list yet. Here's what's new this year:
There are more than 100 million Just Dance players around the world and in Just Dance 2015, the community is as important as ever with the introduction of the all-new Community Remix feature. The feature allows players to record themselves dancing to songs from artists like Ellie Goulding, Pharrell Williams and Calvin Harris and share in the game. The community then votes on their favourites, which the development team will use to create remixed gameplay and ultimately bring fan footage into the game for millions of fans to dance against. Ubisoft is bringing the players into the actual game this year.
Fan-favorite features including the massive multiplayer mode World Dance Floor, video snippet creator Autodance and the sing along Karaoke feature are all back and revamped for the new game. With more than 40 tracks, there's quite literally something for everyone. Get "Happy"with Pharrell Williams, "Walk This Way" with Run DMC & Aerosmith or try "Holding Out for a Hero"with Bonnie Tyler's 1980s power anthem. Whether it's pop, hip-hop or rock you're looking for, check out a selection of Just Dance 2015 tracks:
- "Happy" by Pharrell Williams
- "Problem" by Ariana Grande Ft. Iggy Azalea
- "Walk this Way" by Run DMC & Aerosmith
- "Summer" by Calvin Harris
- "Holding Out for a Hero" by Bonnie Tyler
- "Only You (and You Alone)" by The Platters
- "The Fox" by Ylvis
- "Love It"by Icona Pop ft. Charli XCX
- "Burn" by Ellie Goulding
- "Love Me Again" by John Newman
- "Tetris" by Dancing Bros
Nintendo fused the familiarity of a remote control with the sophistication of motion-sensing technology to come up with an input device for the ages! This black controller comes with the Wii MotionPlus accessory, for a quicker and more accurate reflection of motions in a 3-D space.
Roll up, roll up! The carnival is in town and it's time to party! Join Mario, Luigi, Peach, Yoshi, DK and more of your favourite Nintendo characters as they compete across five brand new game boards and more than 60 new mini games to win the coveted prize: a year's supply of candy! But Bowser isn't about to let them get away with it... For the first Mario Party on Wii, up to four players roll virtual dice and move around the game boards (ranging from a haunted house to a moving train and a treasure island) before competing in crazy mini games that make full use of the Wii Remote; such as tightrope walking, skipping, snow boarding, boat rowing, lassoing and even cake decorating.
As well as the main, madcap multi-player game, Mario Party 8 also features a special single-player only mode, a mini game-only mode, a bazaar where you can unlock new mini games and goodies, and a mode made specifically for playing as Mii characters! The world's enormously popular party video game is getting a lot crazier in Mario Party 8. Whether you're shaking up cola cans or lassoing barrels, you and your friends will be drawn into the action like never before using the Wii Remote.Age from 3 years.
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This fantastic value bundle includes the Wii console in white with Mario Kart, a racing wheel and nunchuk. Mario Kart is one of the most accessible, family fun racing games to date and provides hours of fun!
The Nintendo Wii console has reinvented gaming, transforming it into a truly family-orientated experience to be enjoyed by anyone from age 2 to 92.
The revolutionary motion-sensor system has made gaming more realistic, allowing anyone with no previous experience to have a go - this is about using skills from real life rather than fiddly button pressing or joystick manipulation.
Mario Kart Wii is built for having fun together, with each level allowing players to dive into frenetic racing action on tracks themed from locations in the Super Mario series of games.
You can race up to 12 friends and family simultaneously using Nintendo WiFi Connection, ensuring everyone can get behind the wheel and enjoy the fun!
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- Great value Nintendo Wii bundle
Players will enjoy brand new game mechanics allowing them to create, control and explore a galaxy far, far away. Promising breathtaking visuals and new characters and levels, the game also features signature tongue-in-cheek humour from the LEGO universe.
Over 20 story-based missions and 40 bonus levels spanning the entire Clone Wars era, LEGO Star Wars III: The Clone Wars will allow fans to explore and laugh their way through the Star Wars galaxy in the most humourous, accessible and action packed LEGO game to date.
For the first time, players will experience their favourite stories from Star Wars: The Clone Wars, retold in the amazing LEGO world that fans know and love.
Ground Battles: Brand new. Players take control of battalions of clone troopers against the relentless droid army - building bases, deploying vehicles and calling in reinforcements to defeat opponents.
Scene Swap: Authentic to the Star Wars experience, a new feature allows players to take control of multiple teams in separate locations. Working together to complete various objectives, players will control each team through the press of a button, while playing in single player or in multiplayer co-op modes.
Boss Battles: For the first time in the LEGO Star Wars franchise, fans will fight against massive bosses as seen in The Clone Wars animated series.
Multi-Layered Space Battles: Players will be able to take off in their favourite ships to navigate and fly through multi-layered combat throughout the galaxy.
New Combat Abilities: Characters will have more dynamic moves allowing players greater freedom to battle their opponents. Characters will have new lightsaber abilities including cutting, throwing and climbing.
Age from 7 years.
Disney Epic Mickey 2: The Power of Two returns Mickey Mouse and Oswald the Lucky Rabbit to Wasteland, an alternate world filled with 80 years of forgotten Disney characters and theme park attractions. But for the first time, Mickey and Oswald will join forces as true partners Mickey with his magical paint brush that wields paint and thinner, and Oswald with his powerful remote control that allows him to command electricity. This new co-op play combined with enhanced in-game physics will further enhance the idea that PlayStyle Matters a unique approach to gameplay pioneered by Warren Spector where players dynamically tackle different challenges in order to explore all possibilities and storylines, but with consequences for their chosen actions.
Players can play as Oswald in drop-in, drop-out 2-player co-op mode. The Power of Twoî will be evident as Oswald participates in Mickeys adventure every step of the way.
All in-game characters most notably Oswald The Lucky Rabbit whose voice will be heard for the first time ever are fully voiced by the official voice actors of those characters.
Players will experience Disneys forgotten characters and attractions in all-new levels and further explore levels from the original Disney Epic Mickey game, but now changed, impacted by world-changing events that have shaken Wasteland apart. New 2D levels based on classic Disney animated films and shorts will offer compelling puzzle-based, platforming gameplay.
Age from 7 years.
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Nintendo Wii Mini Console with Super Paper Mario, Super Mario Galaxy
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The Wii Mini is the new version of the Wii console, letting you join the fun of Wii motion gaming at a great entry-level price. The Wii Mini is designed for pure Wii gaming. It's compatible with over 1300 Wii games and small enough to fit almost anywhere! It includes a unique Red Wii Remote Plus controller and Nunchuk, and will work with many other Wii accessories like the Balance Board and Classic Controller. And with no online features to worry about, it's great for kids, families, and even to take away on holiday! For the mini console that provides big fun choose the Wii Mini. Paper Mario isn't just out of this world ... it's out of this dimension. What at first glance appears to be a 2-D sidescroller ripped straight from the pages of the Paper Mario universe soon turns into a 3-D action-adventure that defies all video game logic. Fusing 2-D and 3-D perspectives, not to mention RPG and platformer elements, the game slips back and forth between dimensions. The action sprawls across eight worlds filled with traps, puzzles, bizarre mysteries and items that often draw themselves out of thin air. Oh, and just because Mario's in the title doesn't mean he's the only star - players also get to play as Peach and Bowser.WII Helpline: 0845 6050247.


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Watch the xTablets survive over 1000 drops demonstrating real-world abuse!
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If you placed an order on ApplianceHelp.com the order is still valid and you can check on its status and make changes here on PartSelect.com. Click here for more details.
Below is a list of all parts for the Westinghouse Refrigerator WWSS2601KW6 - REFRIGERATOR. To find the repair part you need, you can browse the list below or you can narrow your choices by searching for a part by name or description.
Sold individually.
The filter is NOT included and the o-ring is also sold separately.
When activated, the auger rotates and pushes ice out of the bin through the chute to the user.
The front trim is not included with this shelf.
Please note that the Trim-Handle will ship only in WHITE. The manufacturer has discontinued the black Trim-Handle (Pictured).
All brand logos are trademarks of their respective owners.
The PartSelect logo is a Registered Trademark of Atlantic Laundry Centres, Ltd.
Copyright © 1999-2014 , Eldis Group Partnership. All rights reserved.


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- Emma Heffernan
- Chonburi
- Thailand
This conversation is closed.
Does anyone know of an original science fair project?
My 14 year old son has wanted to become a scientist since before I can remember. An opportunity has come up for him to enter into a science fair but I need some ideas.
It would be the first science fair he has entered into so it doesn't matter if he wins or not, just the participation I believe would be a good experience for him.
There is no better place to ask than the TED community, all ideas would really be appreciated.
Topics: high school science
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Grant SuttonMar 10 2012: Their was a really cool project a couple Canadian students did launching a lego many into space. http://www.youtube.com/watch?v=MQwLmGR6bPA
I always liked testing chemical reactions. So as a kid if i could design a product that went boom for science that made me happy.
Also you could perhaps try Kevin idea with various ways of filtering the water. Boiling and recondensing water can remove some of the salts, as well as perhaps testing a commercial filter, and perhaps another method.
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Use the "Add to Collection" icon in the top right corner of any video thumbnail when you're logged in (desktop version of site only) or directly from a video page with the "Add to Collection" button under each video.
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