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Date Printed: December 18, 2017: 11:25 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-61000-24

Original Effective Date: 01/01/02

Reviewed: 05/25/17

Revised: 06/15/17

Subject: Deep Brain Stimulation and Responsive Neurostimulation

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Deep Brain Stimulation

Deep brain stimulation (DBS) involves the stereotactic placement of an electrode into the brain (i.e., hypothalamus, thalamus, globus pallidus, or subthalamic nucleus). The electrode is initially attached to a temporary transcutaneous cable for short-term stimulation to validate treatment effectiveness. Several days later, the patient returns to surgery for permanent subcutaneous implantation of the cable and a radiofrequency-coupled or battery-powered programmable stimulator. After implantation, noninvasive programming of the neurostimulator can be adjusted to the patient's symptoms. Since 1997 the U.S. Food and Drug Administration (FDA) has approved several DBS systems.

Responsive Neurostimulation

Responsive neurostimulation (RNS) for the treatment of epilepsy involves the use of 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. In November 2013, the NeuroPace RNS® System was approved by the FDA through the premarket approval process.

POSITION STATEMENT:

Deep Brain Stimulation

Unilateral deep brain stimulation of the thalamus meets the definition of medical necessity when used in the treatment of members with disabling, medically unresponsive tremor due to essential tremor or Parkinson’s disease (PD).

Bilateral deep brain stimulation of the thalamus meets the definition of medical necessity in members with disabling, medically unresponsive tremor in both limbs due to essential tremor or Parkinson disease.

Unilateral or bilateral deep brain stimulation of the globus pallidus or subthalamic nucleus meets the definition of medical necessity for the following members:

a. A minimal score of 30 points on the motor portion of the Unified Parkinson Disease Rating Scale (UPDRS) when the member has been without medication for approximately 12 hours; OR

b. Parkinson disease for at least 4 years.

NOTE: Pulse generator replacement can be expected and may be necessary 3 – 5 years following the initial placement, when the initial procedure was a covered service.

Deep brain stimulation is considered experimental or investigational for all other indications, including but not limited to the following:

The evidence is insufficient to determine the effects of the technology on health outcomes.

Deep brain stimulation is considered experimental or investigational for the treatment of other psychiatric or neurologic disorders, including but not limited to Tourette syndrome, depression, obsessive-compulsive disorder, Alzheimer disease, anorexia nervosa, alcohol addiction, chronic pain, and epilepsy. There is insufficient scientific evidence in peer-reviewed literature to support conclusions on net health outcomes.

Responsive Neurostimulation

Responsive neurostimulation meets the definition of medical necessity for members with partial epilepsy who meet ALL of the following criteria:

Responsive neurostimulation is considered experimental or investigational for all other indications. There is insufficient scientific evidence in peer-reviewed literature to support conclusions on net health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

61850

Twist drill or burr hole for implantation of neurostimulator electrode, cortical

61860

Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical

61863

Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g. 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 (e.g. 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 subcortical site (e.g. 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 (e.g. 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

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 2 or more electrode arrays

61888

Revision or removal of cranial neurostimulator pulse generator or receiver

95970

Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple OR complex brain, spinal cord, OR peripheral (i.e. cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming

95971

Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming

95978

Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, batter 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 (e.g., rate, pulse amplitude and duration, batter 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)

HCPCS Coding:

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

L8689

External recharging system for battery (internal) for use with implantable neurostimulator, replacement only

L8695

External recharging system for battery (external) for use with implantable neurostimulator, replacement only

ICD-10 Diagnoses Codes That Support Medical Necessity:

G20

Parkinson’s disease

G21.11 – G21.9

Secondary Parkinsonism

G24.09 – G24.3
G24.8,
G24.9

Dystonia

G25.0

Essential tremor

G40.001

Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status epilepticus

G40.009

Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status epilepticus

G40.011

Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus

G40.019

Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus

G40.101

Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus

G40.109

Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus

G40.111

Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus

G40.119

Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus

G40.201

Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, with status epilepticus

G40.209

Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus

G40.211

Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus

G40.219

Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus

LOINC Codes:

The following information may be required documentation to support medical necessity: Physician history and physical, attending physician progress notes that include documentation of symptoms, behavior or pharmacologic interventions, plan of treatment, and laboratory studies.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress notes

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Laboratory studies

26436-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

REIMBURSEMENT INFORMATION:

Refer to sections entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products:

The following National Coverage Determinations (NCDs) located at www.cms.gov were reviewed on the last guideline reviewed date:

• Electrical Nerve Stimulators (160.7)

• Deep Brain Stimulation for Essential Tremor and Parkinson’s disease (160.24).

DEFINITIONS:

Disabling, medically unresponsive tremor: tremor causes significant limitation in daily activities; inadequate control is obtained by maximal dosage of medication for at least 3 months prior to implantation of the stimulator.

Essential tremor: a hereditary tremor with onset at varying ages, beginning with a fine rapid tremor of the hands, followed by tremor of the arms, tongue, head, legs, and trunk. It is most evident during active use of the affected muscle and is usually of low to moderate amplitude (frequency of 6 – 12 Hz).

Parkinson’s disease (Paralysis agitans): an idiopathic condition resulting from neuronal degeneration and loss in pigmented brain stem nuclei. It is a slowly progressive disease characterized by mask-like faces, a characteristic tremor of resting muscles, a slowing of voluntary movements, a shuffling, small-stepped gait, peculiar posture, and generalized weakness of the muscles.

Parkinsonian tremor: the resting tremor commonly seen with Parkinsonism, consisting of a coarse, rhythmic tremor (frequency of 3 – 5 Hz) of the hands and forearms and less frequently in the feet, jaw, lips, or tongue.

Tremor: a rhythmic, oscillating, involuntary movement that may involve the extremities, the trunk, or the head and neck. It may be temporarily suppressed by the patient and is absent during sleep. Tremor is frequently worsened by anxiety or fatigue and by a wide variety of medications.

Unified Parkinson Disease Rating Scale (UPDRS): an overall assessment rating tool used to follow the longitudinal course of Parkinson’s disease (PD). It is made up of the following: mentation (mental activity), behavior, mood, activity of daily living, and motor examination. UPDRS is used by clinicians (e.g., physicians, interviewers), to assess the worsening or improvement of PD with treatment and time.

RELATED GUIDELINES:

Spinal Cord Stimulation, 02-61000-05

OTHER:

None Applicable

REFERENCES:

  1. Agency for Healthcare Research and Quality (AHRQ), Stimulation of the Subthalamic Nucleus of the Brain Improves Quality of Life for Patients with Advanced Parkinson’s Disease, accessed at ahrq.gov 04/12/10.
  2. Allen DP, Stegemoller EL, Zadikoff C, et al. Suppression of Deep Brain Stimulation Artifacts From the Electroencephalogram by Frequency-Domain Hampel Filtering, Clinical Neurophysiology, 03/31/10.
  3. Anderson VC, Burchiel KJ, Hogarth P, Favre J, Hammerstad JP. Pallidal vs. subthalamic nucleus deep brain stimulation in Parkinson disease. Arch Neurol. 2005 Apr; 62(4): 554-60.
  4. Aouizerate B, Cuny E, Bardinet E, Distinct Striatal Targets in Treating Obsessive-Compulsive Disorder and Major Depression, J Neurosurg, 2009 March 13.
  5. Blue Cross Blue Shield Association TEC Assessment, Bilateral Deep Brain Stimulation of the Subthalamic Nucleus or the Globus Pallidus Interna for Treatment of Advanced Parkinson’s Disease, Vol. 16, No. 16, 02/02.
  6. Blue Cross Blue Shield Association TEC Assessment, Deep Brain Stimulation of the Thalamus for Tremor, Vol. 12, No. 20, 12/97.
  7. Blue Cross Blue Shield Association. Medical Policy Reference Manual. 7.01.63 Deep Brain Stimulation, 04/17.
  8. Blue Cross Blue Shield Association. Medical Policy Reference Manual. 7.01.143 Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy, 04/17.
  9. Burdick A, Foote KD, Goodman W, et al. Lack of Benefit of Accumbens/Capsular Deep Brain Stimulation in a Patient with Both Tics and Obsessive-Compulsive Disorder, Neurocase, 02/22/10.
  10. Castner JE, Chenery HJ, Copland DA, Coyne TJ, Sinclair F, Silburn PA. Semantic and affective priming as a function of stimulation of the subthalamic nucleus in Parkinson's disease. Brain. 2007 May; 130(Pt 5): 1395-407. Epub 2007 Apr 12.
  11. Centers for Medicare and Medicaid Services (CMS), NCD for Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease (160.24), 04/03, accessed at cms.gov.
  12. Centers for Medicare and Medicaid Services (CMS), NCD for Electrical Nerve Stimulators (160.7), 08/95, accessed at cms.gov.
  13. Cheng-Long Xie, Bei S, et al, Effects of neurostimulation for advanced Parkinson's disease patients on motor symptoms: A multiple-treatments meta-analysas of randomized controlled trials. Sci Rep. 2016; 6: 25285.
  14. ClinicalTrials.gov, Berlin Deep Brain Stimulation Depression Study (BDDS), sponsored by Charite University, Berlin Germany & Medtronic, accessed 04/12/10.
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  19. ClinicalTrials.gov, Effect of Deep Brain Stimulation (DBS) on Lower Urinary Tract (LUT) Function, sponsored by University Hospital Inselspital, Berne, accessed 04/12/10.
  20. ClinicalTrials.gov, Effectiveness of Deep Brain Stimulation for Treating People with Treatment Resistant Obsessive-Compulsive Disorder, sponsored by Butler Hospital, accessed 03/26/13.
  21. ClinicalTrials.gov, Pallidal Stimulation and Gilles de la Tourette Syndrome (STIC), sponsored by Assistance Publique-Hopitauz de Paris, accessed 03/26/13.
  22. ClinicalTrials.gov, Physiological Brain Atlas Development, sponsored by Vanderbilt University, accessed 07/07/09.
  23. ClinicalTrials.gov, Reclaim Deep Brain Stimulation Clinical Study for Treatment-Resistant Depression, sponsored by MedtronicNeuro, accessed 07/07/09.
  24. ClinicalTrials.gov, Study of the Brain Stimulation Effect on Memory Impairment in Alzheimer Disease, Centre Hospitalier Universitaire de Nice, accessed 04/12/10.
  25. ClinicalTrials.gov, Thalamic Deep Brain Stimulation for the Treatment of Refractory Tourette Syndrome, sponsored by Johns Hopkins University, accessed 03/26/13.
  26. ClinicalTrials.gov, Treatment of Gilles de la Tourette Syndrome by Bilateral Stimulation of the Internal Part of the Globus Pallidus, sponsored by Assistance Publique – Paris Hospital, accessed 04/12/10.
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  28. ClinicalTrials.gov, Use of Two DBS Electrodes to Treat Post-Traumatic Tremor, sponsored by University of Florida, accessed 04/12/10.
  29. Deuschl G, Schade-Brittinger C, Krack P, Volkmann J, Schafer H, Botzel K, Daniels C, Deutschlander A, Dillmann U, Eisner W, Gruber D, Hamel W, Herzog J, Hilker R, Klebe S, Kloss M, Koy J, Krause M, Kupsch A, Lorenz D, Lorenzl S, Mehdorn HM, Moringlane JR, Oertel W, Pinsker MO, Reichmann H, Reuss A, Schneider GH, Schnitzler A, Steude U, Sturm V, Timmermann L, Tronnier V, Trottenberg T, Wojtecki L, Wolf E, Poewe W, Voges J; German Parkinson Study Group, Neurostimulation Section. A randomized trial of deep-brain stimulation for Parkinson's disease. N Engl J Med. 2006 Aug 31; 355(9): 896-908.
  30. ECRI HTAIS Forecast. Deep Brain Stimulation for Treatment-Resistant Depression, 05/11.
  31. ECRI Institute, Deep-Brain Stimulation for Dystonia, 02/07.
  32. ECRI Institute, Health Technology Forecast News Brief- Deep Brain Stimulation for Alzheimer’s Disease Prompts Cautious Optimism in Phase 1 Trial, 05/12.
  33. ECRI. Emerging Technology Reports. Deep Brain Stimulation for Treatment-Resistant Obsessive-Compulsive Disorder, 08/10.
  34. ECRI. Health Technology Forecast. Deep-Brain Stimulation shows promise for treatment-resistant depression. Plymouth Meeting, PA: ECRI. Updated 07/24/08.
  35. Goodman WK, Foote KD, et al. Deep Brain Stimulation for Intractable Obsessive Compulsive Disorder: Pilot Study Using a Blinded, Staggered-Onset Design, Biological Psychiatry, March 2010, Vol 67, Issue 6, Pg 535 – 542.
  36. Greenberg BD, Gabriels LA, Malone DA, et al, Deep Brain Stimulation of the Ventral Internal Capsule/Ventral Striatum for Obsessive-Compulsive Disorder: Worldwide Experience, Mol Psychiatry, 2008 May 20.
  37. Guideline Development Subcommittee of the American Academy of Neurology. Evidence-based guideline update:vagus nerve stimulatioon for the treatment of epilepsy:report of the guideline development subcommitte of the American Academy of Neurology. 2013; accessed at aesnet.org 12/12/14.
  38. Halker R, Vargas B, Dodick DW, Cluster Headache: Diagnosis and Treatment, Semin Neurol 2010; 30(2): 175-185.
  39. Haute Autorite de sante/French National Authority for Health. Refractory obsessive compulsive disorders: conventional treatments and deep brain stimulation. Paris: Haute Autorite de sante/French National Authority for Health (HAS), 2005.
  40. Hayes, Inc. Deep Brain Stimulation for Treatment of Movement Disorders of Multiple Sclerosis, 11/06
  41. Hayes, Inc. Hayes Medical Technology Directory – Deep Brain Stimulation for Parkinson’s Disease and Essential Tremor. Lansdale, PA: Hayes, Inc.; Oct 2004. Update performed 10/19/07.
  42. Hayes, Inc. Hayes Search and Summary. Deep Brain Stimulation of Subthalamic Tracts Using the Responsive Neurostimulator (RNS™, Neuropace Inc.) for Treatment of Refractory Epilepsy. Lansdale, PA: Hayes, Inc.; 06/29/07.
  43. Hayes, Inc. Health Technology Brief. Deep Brain Stimulation for Treatment of Movement Disorders of Multiple Sclerosis. Lansdale, PA: Hayes, Inc.; Nov 2006. Update performed 11/14/07.
  44. Hayes, Inc. Hayes Medical Technology Directory – Deep Brain Stimulation for Treatment of Dystonia Lansdale, PA: Hayes, Inc.; Oct 2004. Update performed 11/04/07.
  45. Heck CN, King-Stephens D, Massey AD, et al. Two-year seizure reduction in adults with medically intractable partial onset epilepsy treated with responsive neurostimulation: final results of the RNS System Pivotal trial. Epilepsia. Mar 2014;55(3):432-441.
  46. Henderson J, et al, On Behalf of the ASSFN, The American Association of the Neurological Surgeons, and the Congress of Neurological Surgeons, Deep Brain Stimulation: Indications, Techniques, and Practice Parameters, accessed at assfn.org 03/26/13.
  47. Houeto JL, Karachi C, Mallet L, Pillon B, Yelnik J, Mesnage V, Welter ML, Navarro S, Pelissolo A, Damier P, Pidoux B, Dormont D, Cornu P, Agid Y. Tourette's syndrome and deep brain stimulation. J Neurol Neurosurg Psychiatry. 2005 Jul; 76(7): 992-5.
  48. Houeto JL, Yelnik J, Bardinet E, Vercueil L, Krystkowiak P, Mesnage V, Lagrange C, Dormont D, Le Bas JF, Pruvo JP, Tezenas du Moncel S, Pollak P, Agid Y, Destée A, Vidailhet M; French Stimulation du Pallidum Interne dans la Dystonie Study Group. Acute deep-brain stimulation of the internal and external globus pallidus in primary dystonia: functional mapping of the pallidum. Arch Neurol. 2007 Sep; 64(9): 1281-6.
  49. Kupsch A, Benecke R, Müller J, Trottenberg T, Schneider GH, Poewe W, Eisner W, Wolters A, Müller JU, Deuschl G, Pinsker MO, Skogseid IM, Roeste GK, Vollmer-Haase J, Brentrup A, Krause M, Tronnier V, Schnitzler A, Voges J, Nikkhah G, Vesper J, Naumann M, Volkmann J; Deep-Brain Stimulation for Dystonia Study Group. Pallidal deep-brain stimulation in primary generalized or segmental dystonia. N Engl J Med. 2006 Nov 9; 355(19): 1978-90.
  50. Mallet L, Polosan M, Jaafari N, et al, Subthalamic Nucleus Stimulation in Severe Obsessive-Compulsive Disorder, The New England Journal of Medicine, Vol 359: 2121-2134, 11/13/08.
  51. Mink JW, Clinical Review of DBS for Tourette Syndrome, Front Biosci (Elite Ed.) 2009 June 1; 1: 72-6.
  52. Morrell MJ, RNS System in Epilepsy Study Group. Responsive cortical stimulation for the treatment of medically intractable partial epilepsy. Neurology. Sep 27 2011;77(13):1295-1304.
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  59. Ontario Ministry of Health and Long-Term Care. Deep brain stimulation for Parkinson's disease and other movement disorders. Toronto: Medical Advisory Secretariat, Ontario Ministry of Health and Long-Term Care (MAS), 2005:53. Ministry of Health and Long-Term Care (MAS), 2005:53.
  60. Pahwa R, et al. Practice Parameter: Treatment of Parkinson disease with Motor Fluctuations and dyskinesia (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006; 983-995, April 2006; accessed at aan.com 03/26/13.
  61. U.S. Food and Drug Administration (FDA), Summary of Safety and Probable Benefit, Reclaim™ DBS™ Therapy for OCD – H050003 (Humanitarian Device Exemption Number), notice of approval 02/19/09.
  62. U.S. Food and Drug Administration (FDA). FDA Talk Paper. FDA grants expanded use of brain implant for movement disorder. 04/16/03.
  63. U.S. Food and Drug Administration (FDA). Summary of Safety and Effectiveness. Medtronic Activa® Parkinson’s Control Therapy – P960009/S007. Issued 01/14/02.
  64. U.S. Food and Drug Administration (FDA). Summary of Safety and Effectiveness Data: RNS System 2013.
  65. U.S. Food and Drug Administration (FDA). Summary of Safety and Probable Benefit – H020007. Issued 04/15/03.
  66. Vidailhet M, Vercueil L, Houeto JL, Krystkowiak P, Benabid AL, Cornu P, Lagrange C, Tezenas du Montcel S, Dormont D, Grand S, Blond S, Detante O, Pillon B, Ardouin C, Agid Y, Destee A, Pollak P; French Stimulation du Pallidum Interne dans la Dystonie (SPIDY) Study Group. Bilateral deep-brain stimulation of the globus pallidus in primary generalized dystonia. N Engl J Med. 2005 Feb 3; 352(5): 459-67.
  67. Wojtecki L, Timmermann L, Jörgens S, Südmeyer M, Maarouf M, Treuer H, Gross J, Lehrke R, Koulousakis A, Voges J, Sturm V, Schnitzler A. Frequency-dependent reciprocal modulation of verbal fluency and motor functions in subthalamic deep brain stimulation. Arch Neurol. 2006 Sep;63(9):1273-6.
  68. Xu F, Ma W, Huang Y, et al. Deep brain stimulation of pallidal versus subthalamic for patients with Parkinson's disease: a meta-analysis of controlled clinical trials. Neuropsychiatr Dis Treat. 2016;12:1435-1444.
  69. Zesiewicz TA, Elble R, Louis ED, Hauser RA, Sullivan KL, Dewey RB Jr, Ondo WG, Gronseth GS, Weiner WJ; Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: therapies for essential tremor: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2005 Jun 28; 64(12): 2008-20, accessed at aan.com on 03/26/12.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/25/17.

GUIDELINE UPDATE INFORMATION:

04/15/02

  1. Changed Medical Coverage Guideline name from Deep Brain Stimulation of the Thalamus for Tremor to Deep Brain Stimulation (DBS).
  2. Revised description section of MCG to include 2002 FDA expanded information for Medtronic’s Activa Tremor Control System.
  3. Revised coverage criteria to expand coverage statement for Parkinson’s disease.
  4. Deleted CPT coding that may be used to report DBS.
  5. Added definition for Unified Parkinson Disease Rating Scale (UPDRS).
  6. Updated references.

11/15/03

Review. References updated. Revised Coverage Criteria to mirror new FDA indication.

10/15/04

Review and revision; consisting of addition of CPT codes 61863 – 61868, 61880 – 61888; addition of HCPCS codes E0752 and E0756; addition of definition for dyskinesia; and updated references.

01/01/05

Annual HCPCS update: consisting of addition of 95978, 95979 and revision of 61885, 61886.

10/15/05

Review and revision of guideline; consisting of updated references.

01/01/06

Annual HCPCS update: consisting of the deletion of E0752 and E0756 and the addition of L8680, L8681, L8682, L8683, L8685, L8686, L8687, L8688 and L8689.

10/15/06

Review and revision of guideline consisting of updated references.

01/01/07

Annual HCPCS coding update: consisting of the revision of L8689 and the addition of L8695.

07/15/07

Review; coverage statements maintained; Medicare Advantage section updated; guideline reformatted; references updated.

10/15/08

Review and revision of guideline consisting of updated references.

01/01/09

Annual HCPCS coding update: revised descriptor for codes L8681, L8689, and L8695.

08/15/09

Annual Review: position statement maintained, and updated the description section and references.

01/01/10

Annual HCPCS coding update: revised descriptor for code 61886.

06/15/10

Annual review: position statements maintained and references updated.

10/15/10

Revision; related ICD-10 codes added.

05/15/11

Annual review; position statements maintained, formatting changes, references updated.

10/01/11

Revision; formatting changes.

05/15/12

Annual review; position statements maintained, coding information, program exception, and references updated; formatting changes.

05/15/13

Annual review; position statements maintained, program exception and references updated.

01/01/14

Annual HCPCS update. Added code L8679.

02/15/15

Annual review; Title, DBS position statements, coding, & references updated; RNS position statements added; formatting changes.

10/01/15

Revision; ICD9 & ICD10 coding section updated.

11/01/15

Revision: ICD-9 Codes deleted.

10/01/16

Revision; formatting changes.

06/15/17

Revision; position statement and references updated.

Date Printed: December 18, 2017: 11:25 AM