Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Deep Brain Stimulation requires pre-authorization.

2)    Deep brain stimulation is used to treat advanced Parkinson’s disease, intractable primary dystonia or intractable essential tremor that is interfering with ADLs where other forms of treatment have failed.

1.     Unilateral or bilateral deep brain stimulators (e.g., stimulation of the ventral intermediate thalamic nucleus, globus pallidus, and subthalamic nucleus) is considered medically necessary for the treatment of intractable tremors as a consequence of Parkinson`s disease (G20-G21.9) when all of the following criteria are met:

a.    Disease duration of at least 5 years and

b.    Response to L-DOPA with at least 30% improvement in United Parkinson’s Disease Rating Scale (UPDRS) and

c.    Documentation of treatment fluctuations and/ or dyskinesia.

2.    Unilateral or bilateral deep brain stimulators (e.g., stimulation of the globus pallidus and subthalamic nucleus) is considered medically necessary for the treatment of persons 8 years of age or older with intractable primary dystonia (G24.1-G24.4, G24.8-G24.9), including generalized and/or segmental dystonia, hemidystonia and cervical dystonia.

3.    Unilateral or bilateral deep brain stimulators (e.g., stimulation of the globus pallidus and subthalamic nucleus) is considered medically necessary for the treatment of adults (18 years of age or older) with intractable essential tremor (G25.0).  The tremor needs to be severe enough to interfere with ADLs and needs to have failed (or been intolerant to) an adequate trial of beta blockers and anticonvulsants.

Codes Used In This BI:

1.    Deep brain stimulation (DBS) for tremor from other causes such as trauma, multiple sclerosis (MS), degenerative disorders, metabolic disorders, infectious diseases, and drug-induced movement disorders is considered experimental and investigational because DBS has not been shown to be effective for treating tremors due to these other causes.

2.    DBS is considered experimental and investigational for all other indications, including the treatment of Alzheimer`s disease, Parkinson’s disease-related dysarthria/speech deficits, head or voice tremor, blepharospasm, obesity, depression, epilepsy, chronic cluster headache, obsessive-compulsive disorder, and Tourette syndrome because there is insufficient evidence to support its effectiveness for these indications.

1. Weaver FM, Follett K, Stern M, et al; CSP 468 Study Group. Bilateral deep brain stimulation vs best medical therapy for patients with advanced Parkinson disease: A randomized controlled trial. JAMA. 2009; 301(1):63-73.
2. Deuschl G. Neurostimulation for Parkinson disease. JAMA. 2009; 301(1):104-105. Pan I, Dendukuri N, McGregor M. Subthalamic deep brain stimulation (DBS): Clinical efficacy, safety, and cost compared to medical therapy for the treatment of Parkinson`s disease. Report No. 38. Montreal, QC: Technology Assessment Unit of the McGill University Health Centre (MUHC); November 27, 2009.
3. Gervais-Bernard H, Xie-Brustolin J, Mertens P, et al. Bilateral subthalamic nucleus stimulation in advanced Parkinson`s disease: Five year follow-up. J Neurol. 2009; 256(2):225-233.
4. Tanei T, Kajita Y, Kaneoke Y, et al. Staged bilateral deep brain stimulation of the subthalamic nucleus for the treatment of Parkinson`s disease. Acta Neurochir (Wien). 2009; 151(6):589-594.
5. HAYES Medical Technology Directory, Oct. 15, 2004.

Addendum:

1.    Effective 07/01/2017: Updated to include coverage for medically intractable essential tremor.