Deep Brain Stimulation Treatment Form

Clinical Review Criteria Related to Deep Brain Stimulation Treatment
for Essential Tremor and Parkinson’s Disease

Effective 12/1/2022 (Date of Last Review: 9/13/2022)

Page 1 of 2 © Copyright 2020 Health New England

Clinical Review Criteria Related to Deep Brain Stimulation Treatment for Essential Tremor and Parkinson’s Disease:

Definitions:

Deep Brain Stimulation (DBS): Deep brain stimulation (DBS) involves the surgical placement of electrodes, also called leads, in selected areas of the brain to treat neurological disorders. The electrodes are placed using magnetic resonance imaging (MRI) or computed tomography (CT) to guide the neurosurgeon to the site to be stimulated.
(Humana)

Policy:

I. Criteria for Approval - All Lines of Business: • Health New England has adopted InterQual criteria for all lines of business for deep brain stimulation. • HNE Nurse Reviewers use InterQual. • InterQual criteria - available upon request by members and providers

II. Required Documentation: A. Clinical documentation to support need for deep brain stimulation as per InterQual criteria.

CPT Codes: (Confirmed all on Y/N List)

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 61864 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 61880 Revision or removal of intracranial neurostimulator electrodes 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 a single electrode array with connection to 2 or more electrode arrays

Medical Criteria Disclaimer:

Property of Health New England. All rights reserved. Health New England has adopted InterQual criteria that is an evidence-based clinical decision support solution to help payers, providers and government agencies make clinically appropriate medical utilization decisions. The medical criteria contain the applicable HCPCS codes,

Clinical Review Criteria Related to Deep Brain Stimulation Treatment
for Essential Tremor and Parkinson’s Disease

Effective 12/1/2022 (Date of Last Review: 9/13/2022)

Page 2 of 2 © Copyright 2020 Health New England

diagnoses, and accepted standards of practice and are consistent with Clinical Practice Guidelines. The Medical criteria are applied to each aspect of the prospective, concurrent or retrospective review processes.

Health New England Reviews and approves all InterQual criteria. Input from actively practicing physicians/ practitioners with relevant expertise is provided through the Utilization Management Committee and the Clinical Care Advisory Committee prior to being adopted by Health New England.

Each benefit program defines which services are covered. The conclusion that a particular service, testing or supply is medically necessary does not constitute a representation or warranty that this service, testing or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services, testingor supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare Advantage and Medicaid members. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.

REFERENCES:

NCQA Standard, UM2, Clinical Criteria for Utilization Management Decisions, Element A

National Coverage Determination (NCD) for Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease (160.24). Retrieved April 25, 2022

https://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCDId=279&ncdver=1&DocID=160.24&bc=gAAAAAgAAAAA&
Deep Brain stimulation (DBS), Mayfield Brain and Spine, Retrieved April 25, 2022 https://mayfieldclinic.com/pe- dbs.htm
Deep Brain Stimulation, The Michael J. Fox Foundation for Parkinson’s Research, retrieved April 25, 2022

https://www.michaeljfox.org/news/deep-brain-stimulation Hoehn and Yahr scale (for describing Parkinson’s disease progress) Retrieved April 25, 2022 from:

   Hoehn and Yahr scale - Wikipedia

Unified Parkinson’s Disease Rating Scale (UPDRS), retrieved April 25, 2022 from: Unified Parkinson's Disease Rating Scale (UPDRS) Calculator (mdapp.co)
Parkinson’s Disease Information Page, What research is being done? Retrieved April 25, 2022 from: https://www.ninds.nih.gov/Disorders/All-Disorders/Parkinsons-Disease-Information-Page

Date Policy Changes

7/2022 • Added deep brain stimulation definition • Removed reference to Medecision’s Aerial system for IQ reviews