Anthem Blue Cross Connecticut CG-SURG-108 Stereotactic Radiofrequency Pallidotomy Form

This document addresses the use of stereotactic radiofrequency pallidotomy for the treatment of Parkinson’s disease and other conditions. Stereotactic radiofrequency pallidotomy is a surgical procedure that uses stereotactic (3-D) imaging procedures to identify the target globus pallidus followed by surgical placement of radiofrequency emitting needles to create thermal lesions proposed to relieve the symptoms of Parkinson’s disease and other conditions.

Note: Please see the following for related topics:

• SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation

Clinical Indications

Medically Necessary:

Unilateral stereotactic radiofrequency pallidotomy with microelectrode mapping is considered medically necessary for individuals who meet all of the following criteria:

1. Diagnosis of idiopathic Parkinson's disease (secondary causes of parkinsonism [for example, drug-induced, vascular] or atypical parkinsonian disorders [for example, multiple system atrophy] have been ruled out as a cause for symptoms); and
2. Presence of severe levodopa-induced dyskinesia or disease characterized by severe bradykinesia, dystonia, or akinesia/rigidity, or by marked ‘on-off’ fluctuations; and
3. No history of encephalitis or neuroleptic treatment; and
4. No evidence of dementia or focal brain abnormality on magnetic resonance imaging (MRI); and
5. Absence of medical conditions that might increase risk of hemorrhage (for example, poorly controlled hypertension); and
6. No medical, neurological, or orthopedic disorder that might compromise assessment (for example, cerebrovascular disease, metabolic disorders, spinal stenosis).

Not Medically Necessary:

Unilateral stereotactic radiofrequency pallidotomy with microelectrode mapping is considered not medically necessary when the criteria above are not met.

Bilateral stereotactic radiofrequency pallidotomy is considered not medically necessary for all indications.

The use of unilateral stereotactic radiofrequency pallidotomy is considered not medically necessary for all indications not addressed above.