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Deep Brain Stimulation

Section: Miscellaneous
Effective Date: March 01, 2020
Revised Date: January 22, 2020
Last Reviewed: January 22, 2020

Description

Deep brain stimulation (DBS) involves the stereotactic placement of an electrode into a central nervous system nucleus (e.g., hypothalamus, thalamus, globus pallidus, subthalamic nucleus). DBS is used as an alternative to permanent neuroablative procedures for control of essential tremor, Parkinson disease (PD), and epilepsy.

Criteria

Unilateral or bilateral DBS of the thalamic ventralis intermedius nucleus (VIM) may be considered medically necessary for the treatment of intractable tremors due to essential tremor or PD when ALL of the following criteria are met:

  • Diagnosis of essential tremor or idiopathic PD (with the presence of at least two (2) cardinal PD features – tremor, rigidity, bradykinesia) that is not responding satisfactorily to drug therapy; and
  • No diagnosed dementia, severe depression, cerebral atrophy, or Hoehn and Yahr stage V PD; and
  • No focal lesion of the basal ganglia (e.g., a space occupying lesion or lacunae) at the target site that would negate the result of thalamic stimulation; and
  • Sufficient residual motor function in the upper extremity so that it is reasonable to expect an improvement following the surgery; and
  • Willingness and ability of the individual to cooperate during a conscious operative procedure, as well as during post-surgical evaluations, adjustments of medications and stimulator settings.

Unilateral or bilateral DBS of the subthalamic nucleus (STN) or globus pallidus interna (GPi) for the treatment of PD may be considered medically necessary when ALL of the following criteria are met:

  • PD of at least four (4) years duration; and
  • PD (with the presence of at least two (2) cardinal PD features – tremor, rigidity, bradykinesia) that is not responding satisfactorily to drug therapy; and
  • Presence of disabling PD symptoms or medication side effects (e.g., dyskinesia, motor fluctuations, or disabling “off” periods) despite optimal medical therapy; and
  • No diagnosed dementia, severe depression, cerebral atrophy, or Hoehn and Yahr stage V PD; and
  • PD is levodopa responsive with clearly defined “on” periods; and
  • Willingness and ability to cooperate during conscious operative procedure, as well as during post-surgical evaluations, adjustments of medications and stimulator settings.

DBS may be considered medically necessary when it is used as a treatment for chronic intractable (drug refractory) primary dystonia, including generalized and/or segmental dystonia, hemidystonia, and cervical dystonia (torticollis) in patients seven (7) years of age or above.

Intensive electronic analysis and programming of a deep brain stimulator may be necessary immediately following implantation to achieve optimal stimulus parameters. Recognizing these needs, six (6) such programming visits will be covered within 60 days of the surgical implantation of the deep brain stimulator, and once every 30 days thereafter, as necessary.

DBS is considered experimental/investigational and therefore non-covered when used in ANY ONE of the following situations:

  • For other movement disorders, including but not limited to multiple sclerosis, post-traumatic dyskinesia, and tardive dyskinesia; or
  • For treatment of tremor from other causes such as trauma, degenerative disorders, metabolic disorders, or infectious diseases; or
  • For other indications, including cluster headaches, refractory depression, obsessive/compulsive disorder, and Tourette’s syndrome.

Scientific evidence does not support the use of DBS for any of the above indications.

Bilateral stimulation of the anterior nucleus of the thalamus may be considered medically necessary when ALL of the following criteria have been met:

  • Age 18 years and older; and
  • Individuals with partial onset seizures with or without secondary generalization to tonic-clonic activity; and
  • Individuals with no response to three (3) or more antiepileptic medications.

Bilateral stimulation of the anterior nucleus of the thalamus is considered experimental/investigational when the above criteria are not met.

Procedure Codes

61850 61863 61864 61867 61868 61880 61885
61886 61888 95836 95961 95962 95970 95971
95972 95976 95977 95983 95984 L8680 L8681
L8682 L8683

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 61863, 61864, 61867, 61868, 61885 and 61886

G20 G21.11 G21.19 G21.2 G21.3 G21.4 G21.8
G24.05 G24.09 G24.1 G24.2 G24.3 G24.4 G25.8
G25.0 G25.1 G25.2 G40.001 G40.009 G40.011 G40.019
G40.101 G40.109 G40.111 G40.119 G40.201 G40.209 G40.211
G40.219 G40.311 G40.319 G40.A11 G40.A19 G40.B11 G40.B19
G40.411 G40.419 G40.803 G40.804

Professional Statements and Societal Positions Guidelines

NA

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