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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 10/01/2010 Title: Deep Brain Stimulation
Revision Date: Document: BI267:00
CPT Code(s): 61863, 61864, 61867, 61868
Public Statement

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.


Medical Statement

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:

61863

Implantation of neurostimulators electrode array; first array

61864

Implantation of neurostimulators electrode array; each addtl array

61867

Implantation of neurostimulators electrode array with monitoring; first array

61868

Implantation of neurostimulators electrode array with monitoring; each addtl array


Limits

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.


Background

Unilateral Deep Brain Stimulation of the Thalamus for Tremor

Tremor suppression was total or clinically significant in 82%–91% of operated sides in 179 patients who underwent implantation of thalamic stimulation devices. Results were durable for up to 8 years, and side effects of stimulation were reported as mild and largely reversible. These results are at least as good as those associated with thalamotomy. An additional benefit of deep brain stimulation is that recurrence of tremor may be managed by changes in stimulation parameters.

Unilateral or Bilateral Stimulation of the Globus Pallidus or Subthalamic Nucleus

A wide variety of studies consistently demonstrate that deep brain stimulation of the globus pallidus or subthalamic nucleus results in significant improvements as measured by standardized rating scales of neurologic function. The most frequently observed improvements consist of increased waking hours spent in a state of mobility without dyskinesia, improved motor function during “off” periods when levodopa is not effective, reduction in frequency and severity of levodopa-induced dyskinesia during periods when levodopa is working (“on” periods), improvement in cardinal symptoms of Parkinson’s disease during periods when medication is not working, and in the case of bilateral deep brain stimulation of the subthalamic nucleus, reduction in the required daily dosage of levodopa and/or its equivalents. The magnitude of these changes is both statistically significant and clinically meaningful. The beneficial treatment effect lasts at least for the 6–12 months observed in most trials. While there is not a great deal of long-term follow-up, the available data are generally positive.

 Adverse effects and morbidity are similar to those known to occur with thalamic stimulation. Deep brain stimulation possesses advantages to other treatment options. In comparison to pallidotomy, deep brain stimulation can be performed bilaterally. The procedure is non-ablative and reversible.


Reference
  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.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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