HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
Z-100-008
Topic:
Deep Brain Stimulation
Section:
Miscellaneous
Effective Date:
October 1, 2023
Issued Date:
October 1, 2023
Last Revision Date:
September 2023
Annual Review:
July 2022
 
 

Deep brain stimulation (DBS) involves the stereotactic placement of an electrode into a central nervous system nucleus (e.g., hypothalamus, thalamus, globus pallidus, subthalamic nucleus). DBS can be used as an alternative to permanent neuroablative procedures for control of essential tremor, Parkinson disease (PD), dystonia, obsessive compulsive disorder (OCD), and epilepsy.

Policy Position

Unilateral or bilateral DBS of the thalamic ventralis intermedius nucleus (VIM) may be considered medically necessary for the treatment of intractable tremors due to essential tremor or PD when ALL of the following criteria are met:

  • Diagnosis of essential tremor or idiopathic PD (with the presence of at least two (2) cardinal PD features - tremor, rigidity, bradykinesia) that is not responding satisfactorily to drug therapy; and
  • No diagnosed dementia, severe depression, cerebral atrophy, or Hoehn and Yahr stage V PD; and
  • No focal lesion of the basal ganglia (e.g., a space occupying lesion or lacunae) at the target site that would negate the result of thalamic stimulation; and
  • Sufficient residual motor function in the upper extremity so that it is reasonable to expect an improvement following the surgery; and
  • Willingness and ability of the individual to cooperate during a conscious operative procedure, as well as during post-surgical evaluations, adjustments of medications and stimulator settings.

Unilateral or bilateral DBS of the subthalamic nucleus (STN) or globus pallidus interna (GPi) for the treatment of PD may be considered medically necessary when ALL of the following criteria are met:

  • PD of at least four (4) years duration; and
  • PD (with the presence of at least two (2) cardinal PD features - tremor, rigidity, bradykinesia) that is not responding satisfactorily to drug therapy; and
  • Presence of disabling PD symptoms or medication side effects (e.g., dyskinesia’s, motor fluctuations, or disabling "off" periods) despite optimal medical therapy; and
  • No diagnosed dementia, severe depression, cerebral atrophy, or Hoehn and Yahr stage V PD; and
  • PD is levodopa responsive with clearly defined "on" periods; and
  • Willingness and ability to cooperate during conscious operative procedure, as well as during post-surgical evaluations, adjustments of medications and stimulator settings.

DBS may be considered medically necessary when it is used as a treatment for chronic intractable (drug refractory) primary dystonia, including generalized and/or segmental dystonia, hemidystonia, and cervical dystonia (torticollis) in individuals seven (7) years of age or older.

Intensive electronic analysis and programming of a deep brain stimulator may be necessary immediately following implantation to achieve optimal stimulus parameters. Recognizing these needs, six (6) such programming visits will be covered within 60 days of the surgical implantation of the deep brain stimulator, and once every 30 days thereafter, as necessary.

DBS is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature when used in ANY ONE of the following situations:

  • For other movement disorders, including but not limited to multiple sclerosis, post-traumatic dyskinesia, and tardive dyskinesia; or
  • For treatment of tremor from other causes such as trauma, degenerative disorders, metabolic disorders, or infectious diseases; or
  • For other indications, including cluster headaches, refractory depression, and Tourette's syndrome.

Bilateral stimulation of the anterior nucleus of the thalamus may be considered medically necessary when ALL of the following criteria have been met:

  • Age 18 years and older; and
  • Individuals with partial onset seizures with or without secondary generalization to tonic-clonic activity; and
  • Individuals with no response to three (3) or more antiepileptic medications; and
  • The individual has an average of six (6) or more seizures per month, over the three (3) most recent months prior to DBS implantation (with no more than 30 days in between seizures).
    • Note: DBS has not been evaluated in individuals with less frequent seizures.

Bilateral stimulation of the anterior nucleus of the thalamus not meeting the criteria as indicated in this policy is considered not medically necessary.

61850

61860

61863

61864

61867

61868

61880

61885

61886

61888

95836

95961

95962

95970

95976

95977

95983

95984

L8678

L8679

L8680

L8681

L8682

L8683

L8685

L8686

L8687

L8688

L8689

L8695

 

 

 

 

 




Placement of fiducial markers to guide the implantation of deep brain stimulation electrodes is not to be coded separately for billing purposes, as this is an integral step to the placement of the leads. In instances when fiducial markers are placed on a separate date and/or location to when the electrodes are placed, they still cannot be billed separately.

64999

 

 

 

 

 

 




United States Federal Food and Drug Administration (U.S. FDA)

Humanitarian Device Exemption (HDE)

DBS is U.S. FDA HDE approved for the indication of bilateral stimulation of the anterior limb of the internal capsule, aic, in obsessive compulsive disorder (OCD) when ALL of the following criteria have been met:

  • Age 18 or older; and
  • As an adjunct to medication(s); and
  • As an alternative to anterior capsulotomy for the treatment of chronic, severe, treatment-resistant OCD; and
  • For individuals that have failed at least three (3) or more selective serotonin reuptake inhibitors (SSRIs); and
  • Approved by the institutional review board (IRB) or an appropriate local committee; and
    • Note: Appropriate local committee is defined by the U.S. FDA as a standing committee that has expertise and experience in reviewing and making treatment decisions for clinical care, particularly in applying innovative medical device technologies.
  • Performed in a facility with IRB oversight.
    • Note: Documentation of IRB approval may be required to ensure compliance with HDE indications and applications.

C1767

C1778

C1787

C1816

C1820

C1822

C1826

C1883

C1897

 

 

 

 

 




Related Policies

Refer to Medical Policy S-51, Responsive Neurostimulation of the Treatment of Refractory Partial Epilepsy, for additional information. 


Covered Diagnosis Codes for Procedure Codes: 61863, 61864, 61867, 61868, 61885, and 61886

G20.A1

G20.A2

G20.B1

G20.B2

G20.C

G21.0

G21.11

G21.19

G21.2

G21.3

G21.4

G21.8

G21.9

G24.09

G24.1

G24.2

G24.3

G24.4

G24.8

G24.9

G25.0

G25.1

G25.2

G25.89

G40.001

G40.009

G40.011

G40.019

G40.101

G40.109

G40.111

G40.119

G40.201

G40.209

G40.211

G40.219

Z45.42

 

 

 

 

 



Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Deep Brain Stimulation is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.





Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.