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Effective Date: 10/01/2010 |
Title: Deep Brain Stimulation
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Revision Date:
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Document: BI267:00
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CPT Code(s): 61863, 61864, 61867, 61868
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Public Statement
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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.
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Medical Statement
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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:
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61863
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Implantation of
neurostimulators electrode array; first array
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61864
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Implantation of
neurostimulators electrode array; each addtl array
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61867
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Implantation of
neurostimulators electrode array with monitoring; first
array
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61868
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Implantation of
neurostimulators electrode array with monitoring; each addtl
array
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Limits
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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.
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Background
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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.
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Reference
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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.
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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.
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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.
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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.
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HAYES Medical
Technology Directory, Oct. 15, 2004.
Addendum:
1.
Effective
07/01/2017: Updated to include
coverage for medically intractable essential tremor.
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Application to Products
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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.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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