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.
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:
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:
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:
Bilateral stimulation of the anterior nucleus of the thalamus may be considered medically necessary when ALL of the following criteria have been met:
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 |
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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 |
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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:
C1767 |
C1778 |
C1787 |
C1816 |
C1820 |
C1822 |
C1826 |
C1883 |
C1897 |
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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 |
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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:
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:
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.