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.
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:
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:
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:
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:
Bilateral stimulation of the anterior nucleus of the thalamus is considered experimental/investigational when the above criteria are not met.
Covered Diagnosis Codes for Procedure Codes 61863, 61864, 61867, 61868, 61885 and 61886