Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy

Policy ID: S-51-010

Section: Surgery

Effective Date: November 01, 2019

Revised Date: December 12, 2023

Revision Effective Date: January 01, 2024

Last Reviewed: January 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

Responsive neurostimulation (RNS) for the treatment of epilepsy involves the use of one (1) or more implantable electric leads that serve as both a seizure detection and neurostimulation function. The device is programmed using a proprietary algorithm to recognize seizure patterns from electrocorticography output and to deliver electrical stimulation with the goal of terminating a seizure. One device, the Neuropace RNS System, has United States Food and Drug Administration (U.S. FDA) approval for the treatment of refractory partial epilepsy.

Criteria

RNS may be considered medically necessary for individuals with partial epilepsy who meet ALL of the following criteria:

Are 18 years of age or older; and
Have a diagnosis of partial-onset seizures with one (1) or two (2) well-localized seizure foci identified; and
Have an average of three (3) or more disabling seizures (i.e., motor partial seizures, complex partial seizures, or secondary generalized seizures) per month over the prior three (3) months; and
Are refractory to medical therapy (have failed two (2) or more appropriate antiepileptic medications at therapeutic doses); and
Are not candidates for focal resective epilepsy surgery (i.e., have an epileptic focus near eloquent cerebral cortex; have bilateral temporal epilepsy); and
Do not have any of the following contraindications for RNS placement :
- Three (3) or more specific seizure foci; or
- Presence of primary generalized epilepsy; or
- Presence of a rapidly progressive neurologic disorder.

RNS not meeting the criteria as indicated in this policy is considered not medically necessary.

NOTE: Individual consideration may be considered medically necessary for individuals less that 18 years of age.

Procedure Codes

61850

61860

61863

61864

61867

61868

61880

61885

61886

61888

61889

61891

61892

95836

95970

95983

95984

L8678

L8680

L8686

L8688

Outpatient HCPCS (C Codes)

C1767

C1778

Diagnosis Codes

Covered Diagnosis Codes for Procedure codes 61863, 61864, 61867, 61868, 61885, 61886, 61889, 61891 and 61892.

G40.011

G40.019

G40.111

G40.119

G40.211

G40.219

Z45.42

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-26-2019 New Policy for ND
Internal Medical Policy Committee 9-21-2020 Annual Review-no changes

Internal Medical Policy Committee 9-21-2021 Coding update Effective October 01, 2021

Added procedure codes: 95976; 95977; 95983; and 95984

Internal Medical Policy Committee 7-25-2022 Revision with coding - Effective September 05, 2022

Removed procedure codes 95976 and 95977
Removed diagnosis codes G40.311; G40.319; G40.411; G40.419; G40.803; G40.804; G40.A11; G40.A19; G40.B11 and G40.B19
Added procedure code 95836
Added Outpatient HCPCS (C Codes) C1767 and C1778
Added diagnosis code Z45.42

Internal Medical Policy Committee 3-23-2023 Coding update- Effective April 01, 2023

Added procedure code L8678

Internal Medical Policy Committee 1-16-2024 Coding update - Effective January 01, 2024

Added procedure codes 61889, 61891 and 61892

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-51-009