Deep Brain And Cortical Stimulation Form

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Deep Brain and Cortical Stimulation - Medical Policy
Updated Revision Effective: January 1, 2023 Policy Number:

UM750POL

Approval Date: 12/05/2023

Line(s) of Business:

FF
SF
Medicare
MedSupp-G
MedSupp-I
Medicaid

Description

Deep Brain Stimulation (DBS) is an elective surgical procedure in which electrodes are implanted into certain brain areas. These electrodes, or leads, generate electrical impulses that control abnormal brain activity. The electrical impulses can also adjust for the chemical imbalances within the brain that cause various conditions. Stimulation of brain areas is controlled by a programmable generator that is placed under the skin in the upper chest.

The DBS system involves three distinct components:  The electrode, or lead, is a thin, insulated wire inserted through a small opening in the skull and implanted into a specific brain area.  The extension wire is also insulated and passed under the skin of the head, neck and shoulder, connecting the electrode to the internal pulse generator (IPG).  The IPG is the third piece of the system and is usually implanted under the skin in the upper chest. DBS is a surgical intervention used to treat patients with movement disorders such as essential tremor, Parkinson’s disease and dystonia. It can also be used to control symptoms of obsessive-compulsive disorder and epilepsy. This procedure is utilized when medications are no longer effective for patients maintaining good quality of life. These diseases affect hundreds of thousands of people worldwide. DBS has been used to treat over 160,000 people for various neurological conditions. Responsive Cortical Stimulation (Closed-Loop Implantable Neurostimulator) The RNS® System is intended to detect abnormal electrical brain signals that precede seizures and deliver electrical stimulation in response to try to normalize electrical brain activity and prevent seizures. The device includes a neurostimulator that is placed in the skull and leads that are placed in the seizure-originating areas of the brain. The system’s intended benefits include seizure prevention, fewer adverse events than other neurostimulation methods, and data transmission from the individual’s home to clinicians.

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Policy

I. Criteria for Approval of DBS for Commercial and Medicaid:

 Health New England has adopted InterQual criteria: CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes.

 For members under 18 years of age, the request will be reviewed on a case-by-case basis.

II. There are no MassHealth guidelines for DBS. The above criteria applies.

III. Criteria for Approval of DBS for Medicare:

 Health New England follows National Coverage Determination (NCD) for Deep Brain Stimulation for Essential Tremor and Parkinson’s disease (160.24).

https://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCDId=279&ncdver=1&DocID=160.24&bc=gAAAAAgAAAAA&

IV. DBS for conditions that do not meet above criteria are considered EXPERIMENTAL and INVESTIGATIONAL.

V. Criteria for Approval of Responsive cortical stimulation for all lines of business.

 HNE has adopted InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes.

 For members under 18 years of age, the request will be reviewed on a case-by-case basis.

VI. There are no MassHealth guidelines or Medicare National Coverage Determination (NCD)/Local Coverage Determination (LCD) for Responsive cortical stimulation. The above criteria applies.

VII. Responsive cortical stimulation for conditions that do not meet above criteria are considered EXPERIMENTAL and INVESTIGATIONAL.

Policy Guidelines and Definitions

Policy Guidelines:

Required Documentation:

 Clinical documentation to support need for DBS as per criteria above.

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Coding Guidance

Code
Description
PA 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 YES 61864 each additional array (List separately in addition to primary procedure) NO 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 YES 61880 Revision or removal of intracranial neurostimulator electrodes YES 61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array YES 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 YES 61889 Insertion of skull-mounted cranial neurostimulator pulse generator or receiver, including craniectomy or craniotomy, when performed, with direct or inductive coupling, with connection to depth and/or cortical strip electrode array(s) YES 61891 Revision or replacement of skull-mounted cranial neurostimulator pulse generator or receiver with connection to depth and/or cortical strip electrode array(s) YES CPT® Copyright 2024 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

Deep Brain Stimulation. https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Deep-Brain-Stimulation

National Coverage Determination (NCD) for Deep Brain Stimulation for Essential Tremor and Parkinson’s disease (160.24).
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. https://mayfieldclinic.com/pe-dbs.htm

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Deep Brain Stimulation, The Michael J. Fox Foundation for Parkinson’s Research.
https://www.michaeljfox.org/news/deep-brain-stimulation A modern epilepsy surgery treatment algorithm: Incorporating traditional and emerging technologies. Englot, Epilepsy Behav 2018, 80: 68-74. https://www.sciencedirect.com/science/article/abs/pii/S1525505017310156 Two-year seizure reduction in adults with medically intractable partial onset epilepsy treated with responsive neurostimulation: final results of the RNS System Pivotal trial. Heck et al., Epilepsia 2014, 55: 432-41. https://pubmed.ncbi.nlm.nih.gov/24621228/ Deep brain and cortical stimulation for epilepsy. Sprengers et al., Cochrane Database Syst Rev 2017, 7: CD008497. https://pubmed.ncbi.nlm.nih.gov/28718878/

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 9/2020 Initial policy date 11/2023 Title changed to Deep Brain and Cortical Stimulation. For Deep Brain Stimulation NCD added for Medicare line of business. Added criteria for Responsive cortical stimulation. Criteria added for less than 18 years members. References updated.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this

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service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or 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 and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.