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Coverage criteria policies

Deep Brain Stimulation for Neurological Movement Disorders

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Requires prior authorization:

  • implantation is being requested for a non-covered indication (see below)

Does not require prior authorization:

  • implantation is being done for a covered indication (see diagnoses and criteria below)

Coverage

Deep Brain Stimulation is generally covered subject to the indications listed below, and per your plan documents.

Indications that are covered

Deep Brain Stimulation is covered for the following conditions:

  1. Chronic Intractable Essential Tremor
    1. Patient is diagnosed with moderate to severe uncontrolled essential tremor; and
    2. Standard drug therapies have proven ineffective in controlling the disabling tremor; and
    3. Patient is not diagnosed with dementia, cerebral atrophy, other significant mental impairment, or advanced Parkinson's disease; and
    4. The implantable device is FDA approved for the indication being treated; and
    5. The device is implanted by an experienced neurosurgeon, specially trained in the techniques involved for this condition.
  2. Intractable Parkinson’s Disease
    1. Patient has responded to levodopa; and
    2. Major symptoms of Parkinsonism are present (e.g. tremor, rigidity, dyskinesia, intractable motor fluctuations, bradykinesia); and
    3. Patient is not diagnosed with dementia, cerebral atrophy, other significant mental impairment, or advanced Parkinson's disease; and
    4. The implantable device is FDA approved for the indication being treated; and
    5. The device is implanted by an experienced neurosurgeon, specially trained in the techniques involved for this condition.
  3. Chronic Intractable Primary Dystonia
    1. The device must be ordered by a movement specialist; and
    2. Patient must be 7 years of age or older; and
    3. The implantable device is FDA approved for the indication being treated, and is used in compliance with the Humanitarian Device Exemption specifications of the FDA; and
    4. The device is implanted by an experienced neurosurgeon, specially trained in the techniques involved for this condition.

Indications that are not covered

Deep Brain Stimulation for the treatment of all conditions other than those as described above are considered experimental/investigational and are not covered, including, but not limited to, depression, obsessive compulsive disorder, and other mental health conditions.

Definitions

Deep Brain Stimulation (DBS) involves using an implanted medical device, similar to a cardiac pacemaker, to direct carefully controlled, high-frequency electrical stimulation to specifically targeted areas in the brain. DBS is used as a means to reduce symptoms of movement disorders when optimal medical therapy has failed. The procedure uses special brain imaging (stereotactic) techniques and is performed by a neurosurgeon.

Activa® Tremor Control System (Medtronic) was approved by the FDA under the premarket approval process (PMA) for “unilateral thalamic stimulation for the suppression of tremor in the upper extremity in patients who are diagnosed with essential tremor or Parkinsonian tremor not adequately controlled by medications and where the tremor constitutes a significant functional disability” (FDA, 1997).

Activa® Parkinson's Control Therapy System (Medtronic) was approved by the FDA under the PMA process for “bilateral stimulation of the internal globus pallidus (GPi) or the subthalamic nucleus (STN) for adjunctive therapy in reducing some of the symptoms of advanced, levodopa-responsive Parkinson’s disease that are not adequately controlled with medication” (FDA, 2002).

Activa® Dystonia Therapy System (Medtronic Neurological, Minneapolis, MN) was FDA-approved under the Humanitarian Device Exemption (HDE) process. The device was approved for unilateral or bilateral stimulation of the internal globus pallidus (GPi) or the subthalamic nucleus (STN) to aid in the management of chronic, intractable (i.e., drug-refractory) primary dystonia, including generalized and/or segmental dystonia, hemidystonia, and cervical dystonia (i.e., torticollis) in patients seven years of age and older (FDA, 2003).

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

61863

Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array

61864

Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; each additional array (List separately in addition to primary procedure)

61867

Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortica13/10l site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array

61868

Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; each additional array (List separately in addition to primary procedure)

61880

Revision or removal of intracranial neurostimulator electrodes

61885

Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array

61886

Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays

95978

Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour

95979

Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; each additional 30 minutes after first hour (List separately in addition to code for primary procedure)

L8679

Implantable neurostimulator, pulse generator, any type

L8680

Implantable neurostimulator electrode, each

L8681

Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only

L8682

Implantable neurostimulator radiofrequency receiver

L8683

Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver

L8685

Implantable neurostimulator pulse generator, single array, rechargeable, includes extension

L8686

Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension

L8687

Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension

L8688

Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension

ICD-10CM Codes

Codes

Description

G20

Parkinson's disease

G21.11

Neuroleptic induced parkinsonism

G21.19

Other drug induced secondary parkinsonism

G21.2

Secondary parkinsonism due to other external agents)

G21.3

Postencephalitic parkinsonism

G21.4

Vascular parkinsonism

G21.8

Other secondary parkinsonism

G21.9

Secondary parkinsonism, unspecified

G24.09

Other drug induced dystonia

G24.1

Genetic torsion dystonia

G24.2

Idiopathic nonfamilial dystonia

G24.3

Spasmodic torticollis

G24.8

Other dystonia

G25.0

Essential tremor

G25.1

Drug-induced tremor

G25.2

Other specified forms of tremor

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Cornella, C. Treatment of dystonia. In: UpToDate. Hurtig, H.I. (Ed), UpToDate, Waltham, MA. (Accessed on December 15, 2016.)
  2. Hamani C, Pilitsis J, Rughani AI, et al.; American Society for Stereotactic and Functional Neurosurgery; Congress of Neurological Surgeons; CNS and American Association of Neurological Surgeons. Deep brain stimulation for obsessive-compulsive disorder: systematic review and evidence-based guideline sponsored by the American Society for Stereotactic and Functional Neurosurgery and the Congress of Neurological Surgeons (CNS) and endorsed by the CNS and American Association of Neurological Surgeons. Neurosurgery. 2014 Oct;75(4):327-33.
  3. Hayes, Inc. Hayes Medical Technology Directory Report. Deep Brain Stimulation for Parkinson’s Disease and Essential Tremor. Lansdale, PA: Hayes, Inc.; October, 2004. Reviewed October, 2008. Archived November, 2009.
  4. Hayes, Inc. Hayes Medical Technology Directory Report. Deep Brain Stimulation for Treatment-Resistant Depression. Lansdale, PA: Hayes, Inc.; November, 2012. Reviewed September, 2016.
  5. ECRI Institute. (2012). Deep Brain Stimulation for Treating Non-Parkinsonian Neurologic and Psychiatric Disorders. Plymouth Meeting, PA: ECRI Institute.
  6. ECRI Institute. (2013). Deep Brain Stimulation for Treating Obsessive Compulsive Disorder. Plymouth Meeting, PA: ECRI Institute.
  7. ECRI Institute. (2010). Deep Brain Stimulation for Treatment-Resistant Obsessive-Compulsive Disorder. Plymouth Meeting, PA: ECRI Institute.
  8. National Institute for Health and Care Excellence (NICE). Deep brain stimulation for intractable trigeminal autonomic cephalalgias. March 2011. Available at: http://www.nice.org.uk/guidance Accessed December 15, 2016.
  9. National Institute for Health and Care Excellence (NICE). Deep brain stimulation for tremor and dystonia (excluding Parkinson's disease). August 2006. Available at: http://www.nice.org.uk/guidance . Accessed December 15, 2016.
  10. National Institute for Health and Care Excellence (NICE). Deep brain stimulation for refractory chronic pain syndromes (excluding headache). March 2011. Available at: http://www.nice.org.uk/guidance Accessed December 15, 2016.
  11. National Institute for Health and Care Excellence (NICE). Deep brain stimulation for refractory epilepsy. January 2012. Available at: http://www.nice.org.uk/guidance Accessed December 15, 2016.

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Policy activity

  • 04/01/1998 - Date of origin
  • 02/15/2016 - Effective date
Review date
  • 12/2016
Revision date
  • 02/10/2017

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