Humana Commercial Clinical Policy

Humana Deep Brain Stimulation and Cortical Brain Stimulation Form

Effective Date

01/01/2024

Last Reviewed

NA

Original Document

  Reference



Description

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.

Fiducial markers are small titanium screws, which may be placed into the anesthetized scalp prior to DBS, to assist physicians with stereotactic or computerized targeting for the exact DBS lead location during surgery. After placement, a CT scan is performed to verify accuracy. The fiducial markers remain in place until after DBS leads are inserted.

During DBS lead placement, the individual may be asked to move their fingers or toes or answer questions. This stimulation test helps the surgeon confirm accurate placement and effectiveness of the permanent electrodes in the brain.

Deep Brain Stimulation and Cortical Stimulation

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 07/27/2023

Policy Number: HUM-0472-025

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

These are later connected to a neurostimulator (also referred to as a neurotransmitter or pulse generator) that is implanted under the skin, usually near the collarbone. The battery operated neurostimulator sends high frequency electrical signals to the electrodes which inhibit the activity in that region of the brain. The DBS is programmed with the intensity, frequency and duration according to the individual’s symptoms and can be readjusted as symptoms change.

Directional deep brain stimulation enables the current to be steered precisely to the targeted structural area avoiding areas of stimulation that could cause side effects.

Examples of US Food & Drug Administration (FDA) approved DBS devices include, but may not be limited to:

  • Activa RC neurostimulator for essential tremor (ET) and Parkinson’s disease
  • Activa SC neurostimulator for chronic, intractable primary dystonia including generalized and/or segmental dystonia, hemidystonia and cervical dystonia (torticollis)
  • Infinity DBS system for ET and Parkinson’s disease
  • Reclaim DBS for obsessive compulsive disorder (OCD)
  • SenSight directional lead system (SenSight lead, Percept PC stimulator) for dystonia, epilepsy, ET and Parkinson’s disease
  • Vercise directional system (Cartesia lead, and DBS, Genus, Gevia or PC stimulators) for ET and Parkinson’s disease

Stimulation of the anterior nucleus of the thalamus reduces the frequency of seizures in adults with drug resistant or medically refractory epilepsy providing neuromodulation therapy to change how brain cells work by delivering electrical stimulation to the areas involved in seizures. This stimulation is performed bilaterally. An example of an FDA-approved DBS device for the treatment of drug- resistant epilepsy is the Medtronic DBS System for Epilepsy.

Policy Number: HUM-0472-025

Cortical stimulation is a treatment option for individuals with refractory focal epilepsy and a well delineated seizure focus which may be useful when resective epilepsy surgery is not possible.

Cortical stimulation devices use a closed-loop cortical stimulation unit paired to a seizure detection system. An example of an FDA-approved cortical stimulation system is the NeuroPace RNS System which is used as an adjunct to medication in adults with partial onset seizures from no more than two foci that are refractory to two or more antiepileptic medications. The device is implanted in the skull while the individual is under general anesthesia. The implantable components include a neurostimulator, a depth lead and a cortical strip lead. The external components include the programmer, a laptop computer with proprietary software that has a wand and telemetry interface enabling communication with an implanted RNS neurostimulator. Physicians use the programmer to noninvasively program the detection and stimulation parameters of an implanted device and are able to view the individual's brain electrical activity in real time as well as upload information that has been stored in the RNS neurostimulator.

The system monitors brain activity to detect seizures as they start and delivers electrical stimulation to the seizure focus to stop seizure activity before it becomes clinically apparent. The typical individual is treated with a cumulative total of 5 minutes of stimulation a day and the treatment is reversible.

Magnetic resonance guided focused ultrasound (MRgFUS, [eg, ExAblate Neuro]), is a treatment option that purportedly treats medication refractory ET or movement disorder and tremor dominant Parkinson’s disease. MRgFUS therapy, also called transcranial MR-guided high-intensity focused ultrasound (MRgHIFU), uses a stereotactic head frame/helmet like device with a cooling cap and an individual ultrasound transducer to thermally ablate the thalamus in the ventral intermediate nucleus creating an intracranial therapeutic lesion. The MR images assist in treatment positioning providing real time feedback. The created lesion disrupts the brain activity thought to be responsible for an ET. This procedure is performed unilaterally and is less invasive than DBS implantation or a traditional thalamotomy that involves drilling or boring a hole into the skull to create a therapeutic lesion.

For information regarding laser interstitial thermal therapy and epilepsy, please refer to Laser Interstitial Thermal Therapy Medical Coverage Policy.

Deep Brain Stimulation and Cortical Stimulation

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 07/27/2023

Policy Number: HUM-0472-025

Page: 4 of 22

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Coverage Determination

Services provided by a psychiatrist, psychologist or other behavioral health professionals are subject to the provisions of the applicable behavioral health benefit.

DBS for Parkinson’s Disease

Humana members may be eligible under the Plan for unilateral or bilateral DBS when ALL of the following criteria are met:

  • Disabling, medically intractable Parkinson’s disease; AND
  • Individual is able to properly operate the neurostimulator; AND
  • Motor response complications not controlled by pharmacologic therapy; AND
  • Symptoms of movement disorder, which cause significant limitations in daily activities; AND
  • The device is FDA approved

Humana members may be eligible under the Plan for bilateral stimulation of the internal globus pallidus (GPi) or the subthalamic nucleus (STN) when the following criteria are met:

  • Levodopa responsive Parkinson’s disease of at least 4 years duration; AND
  • Motor response complications not controlled by pharmacologic therapy; AND
  • The device is FDA approved

DBS for ET

Humana members may be eligible under the Plan for unilateral or bilateral DBS when ALL of the following criteria are met:

  • Disabling, medically intractable ET; AND
  • Individual is able to properly operate the neurostimulator; AND
  • Individual is not pregnant; AND
  • Motor response complications not controlled by pharmacologic therapy; AND
  • No presence of coagulopathies, dementia, moderate to severe depression or previous ablative brain surgery; AND
  • Symptoms of movement disorder, which cause limitations in daily activities; AND
  • The device is FDA approved

DBS for Dystonia

Humana members may be eligible under the Plan for unilateral or bilateral stimulation of the internal globus pallidus (GPi) or the subthalamic nucleus (STN) when the following criteria are met:

  • 7 years of age or older; AND
  • Individual is able to properly operate the neurostimulator; AND
  • Individual is not pregnant; AND
  • No presence of coagulopathies, dementia, moderate to severe depression or previous ablative brain surgery; AND
  • The device is FDA approved

AND any of the following:

  • Chronic primary dystonia, including generalized and or segmental dystonia, hemidystonia and cervical dystonia (torticollis) with motor response complications not controlled by pharmacologic therapy; OR

Deep Brain Stimulation and Cortical Stimulation

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 07/27/2023

Policy Number: HUM-0472-025

Page: 5 of 22

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

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  • Secondary tardive dyskinesia/dystonia from chronic levodopa treatment for Parkinson’s disease or chronic antidopaminergic treatment for psychiatric disease with motor response complications not controlled by pharmacologic therapy

DBS for Epilepsy

Humana members may be eligible under the Plan for bilateral stimulation of the anterior nucleus of the thalamus (eg, Medtronic DBS system) when the following criteria are met:

  • 18 years of age or older; AND
  • Average of 6 or more seizures per month over the 3 most recent months prior to implant of the DBS system with no more than 30 days between seizures; AND
  • Individual is able to or has the necessary assistance to properly operate the device; AND
  • Individual is not pregnant or nursing; AND
  • No presence of coagulopathies; AND
  • Partial onset seizures with or without secondary generalization; AND
  • Seizures refractory to 3 or more antiepileptic medications; AND
  • The device is FDA approved

Humana members may be eligible under the Plan for the replacement/revision of a DBS generator/battery and/or lead/electrode and/or programmer if the original generator/lead/programmer is no longer under warranty and cannot be repaired.

Note: The criteria for DBS are not consistent with the Medicare National Coverage Policy, and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Deep Brain Stimulation and Cortical Stimulation
Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 07/27/2023

Policy Number: HUM-0472-025

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Cortical Stimulation

Humana members may be eligible under the Plan for cortical stimulation (eg, NeuroPace RNS) when ALL of the following criteria are met:

  • 18 years of age or older; AND
  • Partial-onset seizures; AND
  • Currently averaging 3 or more disabling seizures (eg, partial motor seizures, complex partial seizures and/or secondarily generalized seizures) a month over the 3 most recent months; AND
  • Individual is able to or has the necessary assistance to properly operate the device or magnet; AND
  • Individual is not pregnant; AND
  • No more than 2 epileptogenic foci localized by diagnostic testing; AND
  • Refractory to 2 or more antiepileptic medications; AND
  • No other implanted medical devices that deliver electrical energy to the brain; AND
  • Not currently a candidate for resective epilepsy surgery; AND
  • Not high risk for surgical complications such as active systemic infection, coagulation disorders (such as the use of antithrombotic therapies) or platelet count below 50,000; AND
  • The device is FDA approved

Humana members may be eligible under the Plan for the replacement/revision of a cortical stimulator/battery and/or leads and/or programmer if the original stimulator/lead/programmer is no longer under warranty and cannot be repaired.

Deep Brain Stimulation and Cortical Stimulation
Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 07/27/2023

Policy Number: HUM-0472-025

Page: 8 of 22

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

MRgFUS/MRgHIFU for ET

Humana members may be eligible under the Plan for MRgFUS/MRgHIFU (ExAblate Neuro) when ALL of the following criteria are met:

  • Disabling ET; AND
  • Medication refractory ET (defined as refractory to at least 2 trials of medical therapy, including at least 1 first-line agent); AND
  • Moderate to severe postural or intention tremor of the dominant hand; AND
  • Not a surgical candidate for DBS (eg, advanced age, anticoagulant therapy, or surgical comorbidities)
Coverage Limitations

DBS

Humana members may NOT be eligible under the Plan for DBS for any indications other than those listed above including, but not limited to the following:

  • Cerebral palsy; OR
  • Chronic neuropathic pain; OR
  • Cluster headaches; OR
  • Depression; OR
  • Movement disorder caused by multiple sclerosis (MS); OR
  • Obsessive compulsive disorder (OCD); OR
  • Orthostatic tremor; OR
  • Tourette syndrome

These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

The placement of fiducial markers is considered integral to the primary procedure and not separately reimbursable.

Deep Brain Stimulation and Cortical Stimulation
Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 07/27/2023

Policy Number: HUM-0472-025

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Cortical Stimulation

Humana members may NOT be eligible under the Plan for cortical stimulation for any indications other than those listed above. This is considered experimental/ investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

MRgFUS/MRgHIFU

Humana members may NOT be eligible under the Plan for magnetic resonance image-guided focused ultrasound or high-intensity focused ultrasound for any indications other than those listed above. This is considered experimental/ investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Background

Additional information about chronic neuropathic pain, cluster headaches, depression, epilepsy, OCD, Parkinson’s disease and Tourette’s syndrome may be found from the following websites:

  • American Academy of Neurology
  • National Institute of Mental Health
  • National Institute of Neurological Disorders and Stroke
  • National Library of Medicine

Alternatives to deep brain or cortical brain stimulation include, but may not be limited to, the following:

Medical Alternatives

  • Prescription drug therapy
  • Surgical treatment

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Deep Brain Stimulation and Cortical Stimulation
Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 07/27/2023

Policy Number: HUM-0472-025

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Humana may offer a disease management program for this condition.

The member may call the number on his/her identification card to ask about our programs to help manage his/her care.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

Deep Brain Stimulation and Cortical Stimulation
Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 07/27/2023

Policy Number: HUM-0472-025

Page: 11 of 22

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Deep Brain Stimulation and Cortical Stimulation
Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 07/27/2023

Policy Number: HUM-0472-025

Page: 12 of 22

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Unlisted procedure, nervous system

Not Covered if used to report any procedure outlined in Coverage Limitations section. The placement of fiducial markers is considered integral to the primary procedure and not separately reimbursable.

Deep Brain Stimulation and Cortical Stimulation
Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 07/27/2023

Policy Number: HUM-0472-025

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • 95961 - Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of attendance by a physician or other qualified health care professional.
  • 95962 - Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; each additional hour of attendance by a physician or other qualified health care professional (List separately in addition to code for primary procedure).
  • 95970 - Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/transmitter, without programming.
  • 95983 - Electronic analysis of implanted neurostimulator pulse generator/transmitter by physician or other qualified health care professional; with brain neurostimulator pulse generator/transmitter programming, first 15 minutes face-to-face time with physician or other qualified health care professional.
  • 95984 - Electronic analysis of implanted neurostimulator pulse generator/transmitter by physician or other qualified health care professional; with brain neurostimulator pulse generator/transmitter programming, each additional 15 minutes face-to-face time with physician or other qualified health care professional (List separately in addition to code for primary procedure).
  • 0398T - Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed.
Deep Brain Stimulation and Cortical Stimulation
Effective Date: 01/01/2024
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Review Date: 07/27/2023

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled.

Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • C1787 - Patient programmer, neurostimulator
  • C1816 - Receiver and/or transmitter, neurostimulator (implantable)
  • C1820 - Generator, neurostimulator (implantable), with rechargeable battery and charging system
  • C1822 - Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system
  • C1826 - Generator, neurostimulator (implantable), includes closed feedback loop leads and all implantable components, with rechargeable battery and charging system
  • C1827 - Generator, neurostimulator (implantable), non-rechargeable, with implantable stimulation lead and external paired stimulation controller
  • C1883 - Adaptor/extension, pacing lead or neurostimulator lead P (implantable)
  • C1897 - Lead, neurostimulator test kit (implantable)
  • 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
  • 18683 - Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
  • 18685 - Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
Deep Brain Stimulation and Cortical Stimulation
Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 07/27/2023

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  • L8686 - Implantable neurostimulator pulse generator, single array, P nonrechargeable, includes extension
  • 8687 - Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
  • 18688 - Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension
  • 18689 - External recharging system for battery (internal) for use with implantable neurostimulator, replacement only

References

  • American Academy of Child & Adolescent Psychiatry (AACAP). Clinical practice guideline for the assessment and treatment of children and adolescents with major and persistent depressive disorders. http://www.aacap.org. Published October 2022. Accessed July 14, 2023.
  • American Academy of Neurology (AAN). Evidence-based guideline update: treatment of essential tremor. https://www.aan.com. Published October 19, 2011. Updated April 30, 2014. Accessed July 14, 2023.
  • American Academy of Neurology (AAN). Evidence-based guideline update: treatment of tardive syndromes. https://www.aan.com. Published July 30, 2013. Updated October 12, 2019. Accessed July 14, 2023.
  • American Academy of Neurology (AAN). Practice guideline: the treatment of tics in people with Tourette syndrome and chronic tic disorders. https://www.aan.com. Published May 7, 2019. Updated April 30, 2022. Accessed July 14, 2023.
  • American Academy of Sleep Medicine. Management of REM sleep behavior disorder: an American Academy of Sleep Medicine clinical practice guideline. https://sleepeducation.org/. Published April 1, 2023. Accessed July 14, 2023.
  • American Heart Association/American Stroke Association (AHA/ASA).
  • American Heart Association/American Stroke Association (AHA/ASA). Guidelines for adult stroke rehabilitation and recovery. https://www.heart.org/. Published May 4, 2016. Accessed July 14, 2023.
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    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
  • American Psychiatric Association (APA). Guideline watch for the practice guideline for the treatment of patients with obsessive-compulsive disorder. https://www.psychiatryonline.org. Published March 2013. Accessed July 14, 2023.
  • American Psychiatric Association (APA). Practice guideline for the treatment of patients with major depressive disorder. https://www.psychiatryonline.org. Published October 2010. Accessed July 14, 2023.
  • American Psychiatric Association (APA). Practice guideline for the treatment of patients with obsessive-compulsive disorder. https://www.psychiatryonline.org. Published July 2007. Accessed July 14, 2023.
  • Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Deep brain stimulation for essential tremor and Parkinson’s disease. (160.24). https://www.cms.gov. Published April 1, 2003. Accessed July 14, 2023.
  • Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Electrical nerve stimulators (160.7). https://www.cms.gov. Published April 7, 1995. Accessed July 14, 2023.
  • Congress of Neurological Surgeons (CNS). Congress of Neurological Surgeons systematic review and evidence-based guideline on subthalamic nucleus and globus pallidus internus deep brain stimulation for the treatment of patients with Parkinson’s disease. https://www.cns.org. Published March 2018. Accessed July 14, 2023.
  • Congress of Neurological Surgeons (CNS). Deep brain stimulation for obsessive-compulsive disorder: systematic review and evidence-based guideline. https://www.cns.org. Published July 18, 2014. Updated 2020. Accessed July 14, 2023.
  • ECRI Institute. Clinical Evidence Assessment. Deep brain stimulation for treatment-resistant epilepsy. https://www.ecri.org. Published May 23, 2023. Accessed July 6, 2023.
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    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
  • ECRI Institute. Clinical Evidence Assessment. ExAblate Neuro (InSightec, Inc.) for treating essential tremor. https://www.ecri.org. Published July 5, 2017. Updated July 21, 2020. Accessed July 7, 2023.
  • ECRI Institute. Clinical Evidence Assessment. ExAblate Neuro (InSightec, Inc.) for treating tremor-dominant Parkinson disease. https://www.ecri.org. Published July 23, 2020. Accessed July 6, 2023.
  • ECRI Institute. Clinical Evidence Assessment. Infinity Deep Brain Stimulation System (Abbott Laboratories) for treatment-resistant depression. https://www.ecri.org. Published January 4, 2023. Accessed July 6, 2023.
  • ECRI Institute. Clinical Evidence Assessment. Neuropace RNS systems (Neuropace, Inc.) for treating epilepsy. https://www.ecri.org. Published September 4, 2018. Updated August 5, 2022. Accessed July 7, 2023.
  • ECRI Institute. Clinical Evidence Assessment. NeuroSmart system (Alpha Omega) microelectrode recording for deep brain stimulation. https://www.ecri.org. Published February 17, 2021. Accessed July 6, 2023.
  • ECRI Institute. Clinical Evidence Assessment. Overview of deep brain stimulators for treating Parkinson’s disease.
  • ECRI Institute. FDA Approvals & Clearances. SureTune4 Software. https://www.ecri.org. Published September 3, 2021. Accessed July 6, 2023.
  • Hayes, Inc. Evidence Analysis Research Brief. Magnetic resonance–guided high intensity focused ultrasound for essential tremor. https://evidence.hayesinc.com. Published September 20, 2022. Accessed July 10, 2023.
  • Hayes, Inc. Evolving Evidence Review. NeuroPace RNS system (NeuroPace Inc.) for treatment of drug-resistant epilepsy. https://evidence.hayesinc.com. Published September 7, 2021. Accessed July 10, 2023.
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Hayes, Inc. Health Technology Assessment. Deep brain stimulation for the anterior nucleus of the thalamus for treatment of refractory epilepsy. https://evidence.hayesinc.com. Published November 14, 2019. Updated December 29, 2022. Accessed July 10, 2023.
  • Hayes, Inc. Health Technology Assessment. Deep brain stimulation for the treatment of refractory obsessive-compulsive disorder. https://evidence.hayesinc.com. Published August 19, 2020. Updated July 13, 2023. Accessed July 14, 2023.
  • Hayes, Inc. Health Technology Brief. Magnetic resonance guided focused ultrasound (MRgFUS) unilateral thalamotomy for essential tremor (ARCHIVED). https://evidence.hayesinc.com. Published April 10, 2019. Updated April 19, 2021. Accessed July 10, 2023.
  • MCG Health. Deep brain stimulation (DBS). 27th edition. https://www.mcg.com. Accessed June 19, 2023.
  • MCG Health. Deep brain stimulation (DBS): behavioral health care. 27th edition. https://www.mcg.com. Accessed June 19, 2023.
  • Medtronic. Indications, safety and warnings. https://www.medtronic.com. Published February 2020. Updated June 2022. Accessed July 20, 2023.
  • UpToDate, Inc. Bipolar disorder in adults: overview of neuromodulation procedures. https://www.uptodate.com. Updated June 2023. Accessed July 10, 2023.
  • UpToDate, Inc. Central neuropathic facial pain. https://www.uptodate.com. Updated June 2023. Accessed July 10, 2023.
  • UpToDate, Inc. Cerebral palsy: treatment for spasticity, dystonia and associated orthopedic issues. https://www.uptodate.com. Updated June 2023. Accessed July 10, 2023.
  • UpToDate, Inc. Cervical dystonia: treatment and prognosis. https://www.uptodate.com. Updated June 2, 2023. Accessed July 10, 2023.
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • UpToDate, Inc. Cluster headache: treatment and prognosis.https://www.uptodate.com. Updated June 2023. Accessed July 11, 2023.
  • UpToDate, Inc. Deep brain stimulation for treatment of obsessive-compulsive disorder. https://www.uptodate.com. Updated June 2023. Accessed July 11, 2023.
  • UpToDate, Inc. Device assisted and lesioning procedures for Parkinson disease. https://www.uptodate.com. Updated June 7, 2023. Accessed July 11, 2023.
  • UpToDate, Inc. Evaluation and management of drug resistant epilepsy. https://www.uptodate.com. Updated June 2023. Accessed July 10, 2023.
  • UpToDate, Inc. Overview of tremor. https://www.uptodate.com. Updated June 2023. Accessed July 14, 2023.
  • UpToDate, Inc. Short lasting unilateral neuralgiform headache attacks: treatment. https://www.uptodate.com. Updated June 2023. Accessed July 11, 2023.
  • UpToDate, Inc. Surgical treatment of essential tremor. https://www.uptodate.com. Updated June 2023. Accessed July 11, 2023.
  • UpToDate, Inc. Symptom management of multiple sclerosis in adults. https://www.uptodate.com. Updated June 2023. Accessed July 14, 2023.
  • UpToDate, Inc. Tardive dyskinesia: prevention and treatment. https://www.uptodate.com. Updated June 12, 2023. Accessed July 11, 2023.
  • UpToDate, Inc. Tourette syndrome: management.https://www.uptodate.com. Updated June 2023. Accessed July 11, 2023.
  • UpToDate, Inc. Treatment of dystonia in children and adults. https://www.uptodate.com. Updated June 2, 2023. Accessed July 11, 2023.
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    Policy Number: HUM-0472-025

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    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • UpToDate, Inc. Treatment of myoclonus. https://www.uptodate.com. Updated June 2023. Accessed July 10, 2023.
  • UpToDate, Inc. Unipolar depression in adults: overview of neuromodulation procedures. https://www.uptodate.com. Updated June 2023. Accessed July 11, 2023.
  • UpToDate, Inc. Unipolar depression in adults: treatment with surgical approaches. https://www.uptodate.com. Updated June 2023. Accessed July 11, 2023.
  • US Food & Drug Administration (FDA). Summary of safety and effectiveness data: Activa Parkinson's control therapy. https://www.fda.gov. Published January 14, 2002. Accessed August 2, 2016.
  • US Food & Drug Administration (FDA). Summary of safety and effectiveness data: Brio neurostimulation system. https://www.fda.gov. Published June 12, 2015. Accessed August 2, 2016.
  • US Food & Drug Administration (FDA). Summary of safety and effectiveness data: Exablate Neuro. https://www.fda.gov. Published October 29, 2021. Accessed May 5, 2022.
  • US Food & Drug Administration (FDA). Summary of safety and effectiveness data: Medtronic DBS System for Epilepsy. https://www.fda.gov. Published April 27, 2018. Accessed July 18, 2019.
  • US Food & Drug Administration (FDA). Summary of safety and effectiveness data: NeuroPace RNS system. https://www.fda.gov. Published November 5, 2012. Accessed August 2, 2016.
  • US Food & Drug Administration (FDA). Summary of safety and effectiveness data: Vercise PC, Vercise Gevia and Vercise Genus Deep Brain Stimulation (DBS) System. https://www.fda.gov. Published October 20, 2021. Accessed July 13, 2023.
    • Deep Brain Stimulation and Cortical Stimulation
    Effective Date: 01/01/2024
    Revision Date: 01/01/2024
    Review Date: 07/27/2023

    Policy Number: HUM-0472-025

    Page: 21 of 22

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • US Food & Drug Administration (FDA). Summary of safety and probable benefit: Activa dystonia therapy. https://www.fda.gov. Published April 15, 2003. Accessed November 4, 2013.
  • US Food & Drug Administration (FDA). Summary of safety and probable benefit: Reclaim deep brain stimulation for obsessive compulsive disorder (OCD) therapy. https://www.fda.gov. Published February 19, 2009. Accessed November 4, 2013.
  • VA/DoD Clinical Practice Guideline. The Management of major depressive disorder. http://www.va.gov/. Published April 26, 2022.
Deep Brain Stimulation and Cortical Stimulation
Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 07/27/2023

Policy Number: HUM-0472-025

Page: 22 of 22

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.