Medical Policy: 07.01.59
Original Effective Date: November 2000
Reviewed: September 2015
Revised: September 2015
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Deep brain stimulation (DBS) involves the stereotactic placement of an electrode into the brain (i.e. hypothalamus, thalamus, globus pallidus, subthalmic nucleus). DBS is used as an alternative to permanent neuroablation procedures for control of essential tremor (ET) and Parkinson disease (PD). DBS is also being evaluated for the treatment of variety of other neurological and psychiatric disorders, including epilepsy, dystonia, cluster headache, Tourette syndrome, depression, and obsessive compulsive disorder (OCD).
DBS involves the stereotactic placement of an electrode into the brain (ie, hypothalamus, thalamus, globus pallidus, or subthalamic nucleus). The electrode is initially attached to a temporary transcutaneous cable for short-term stimulation to validate treatment effectiveness. Several days later, the patient returns to surgery for permanent subcutaneous implantation of the cable and a radiofrequency-coupled or battery-powered programmable stimulator. The electrode is typically implanted unilaterally on the side corresponding to the most severe symptoms. However, use of bilateral stimulation using 2 electrode arrays has also been investigated in patients with bilateral, severe symptoms. After implantation, noninvasive programming of the neurostimulator can be adjusted to the patient's symptoms. This feature may be important for patients with PD, whose disease may progress over time, requiring different neurostimulation parameters. Setting the optimal neurostimulation parameters may involve the balance between optimal symptom control and appearance of adverse effects of neurostimulation, such as dysarthria, disequilibrium, or involuntary movements.
DBS has been most thoroughly investigated as an alternative to thalamotomy for unilateral control of ET and tremor associated with PD. More recently, there has been research interest in the use of DBS of the globus pallidus or subthalamic nucleus as a treatment of other parkinsonian symptoms, such as rigidity, bradykinesia, or akinesia. Another common morbidity associated with PD is the occurrence of motor fluctuations, referred to as "on and off" phenomena, related to the maximum effectiveness of drugs (ie, “on” state) and the nadir response during drug troughs (ie, “off”state). In addition, levodopa, the most commonly used anti-Parkinson drug, may be associated with disabling drug-induced dyskinesias. Therefore, the optimal pharmacologic treatment of PD may involve a balance between optimal effects on PD symptoms versus the appearance of drug-induced dyskinesias. The effect of DBS on both PD symptoms and drug-induced dyskinesias has also been studied.
DBS has also been investigated in patients with primary and secondary dystonia, defined as a neurologic movement disorder characterized by involuntary muscle contractions, which force certain parts of the body into abnormal, contorted, and painful movements or postures. Dystonia can be classified according to age of onset, bodily distribution of symptoms, and cause. Age of onset can occur during childhood or during adulthood. Dystonia can affect certain portions of the body (focal dystonia and multifocal dystonia) or the entire body (generalized dystonia). Torticollis is an example of a focal dystonia. Primary dystonia is defined when dystonia is the only symptom unassociated with other pathology. Treatment options for dystonia include oral or injectable medications (ie, botulinum toxin) and destructive surgical or neurosurgical interventions (ie, thalamotomies or pallidotomies) when conservative therapies fail. Secondary dystonia is a dystonia brought on by an inciting event, such as a stroke, trauma, or drugs. Tardive dystonia is a form of drug-induced secondary dystonia.
DBS has been investigated in patients with chronic cluster headaches. Cluster headaches occur as episodic attacks of severe pain lasting from 30 minutes to several hours. The pain is usually unilateral and localized to the eye, temple, forehead, and side of the face. Autonomic symptoms that occur with cluster headaches include ipsilateral facial sweating, flushing, tearing, and rhinorrhea. Cluster headaches occur primarily in men and have been classified as vascular headaches that have been associated with high blood pressure, smoking, alcohol use, etc. However, the exact pathogenesis of cluster headaches is uncertain. Positron emission tomography scanning and magnetic resonance imaging (MRI) have shown the hypothalamic region may be important in the pathogenesis of cluster headaches. Alterations in hormonal/serotonergic function may also play a role. Treatment of cluster headaches includes pharmacologic interventions for acute episodes and prophylaxis and surgical procedures such gamma knife radiosurgery of the trigeminal nerve. The use of DBS is considered investigational as the current evidence on the efficacy is limited and inconsistent, and the evidence on safety shows that there are serious but well-known adverse effects.
The role of DBS in treatment of other treatment-resistant neurologic and psychiatric disorders, particularly Tourette syndrome, epilepsy, OCD, and major depressive disorders, is also being investigated. Ablative procedures are irreversible and, though they have been refined, remain controversial treatments for intractable illness. Interest has shifted to neuromodulation through DBS of nodes or targets within neural
circuits involved in these disorders. Currently, a variety of target areas are being studied.
DBS has been shown to be effective for the treatment of essential tremor (ET), advanced Parkinson disease (PD) and dystonia. Evidence for efficacy of DBS for Tourette syndrome, treatment of resistant depression, OCD, Alzheimer disease, anorexia nervosa, alcohol addiction, chronic pain, epilepsy, tardive dystonia, and cluster headache is based on experience with small number of patients. In addition, the appropriate candidates and most effective target areas for DBS are under investigation. Additional controlled studies with larger number of subjects are required to evaluate the role of DBS for these conditions.
Cerebellar stimulation/pacing is electrical stimulation using surgically implanted electrodes on the surface of the cerebellum and has been proposed as on way to treat some neurological disorders. At this time, there is inadequate information available to make an assessment of the clinical usefulness of this procedure and therefore, is considered investigational.
Practice Guidelines and Position Statements
American Academy of Neurology (AAN)
2006 Guidelines from AAN on the treatment of Parkinson disease (PD) with motor fluctuations and dyskinesia states that deep brain stimulation (DBS) of the subthalamic nucleus (STN) may be considered to improve motor function and reduce off time, dyskinesia and medication usage (Level C). There is insufficient evidence to support or refute the efficacy of DBS of the GPi or VIM nucleus of the thalamus in reducing off time, dyskinesia or medication usage, or to improve motor function in PD patients.
2011 The American Academy of Neurology (AAN) published an updated guideline on the treatment of essential tremor (ET). There were no changes from the conclusions and recommendations of the 2005 practice parameters regarding DBS for ET. The guidelines stated bilateral DBS of the thalamic nucleus may be used to treat medically refractory limb tremor in both upper libs (level C possibly effective), but there were insufficient data regarding the risk/benefit ration of bilateral versus unilateral DBS in the treatment of limb tremor. There was insufficient evidence to make recommendation regarding the use of thalamic for head or voice tremor (Level U, treatment is unproven).
2013 Evidence based guideline from the AAN on the treatment of tardive syndromes states that the available evidence which consists of class IV studies comprising of case reports or small case series, is insufficient to support or refute pallidal deep brain stimulation for tardive syndromes.
American Psychiatric Association
2007 American Psychiatric Association practice guideline for the treatment of patients with obsessive compulsive disorder states DBS may be recommended on the basis of individual circumstances. In the 2013 Guideline watch practice parameter for the treatment of patients with Obsessive-Compulsive Disorder states DBS and ablative neurosurgical treatment for OCD should be performed only at sites with expertise in both OCD and these treatment approaches.
2010 American Psychiatric Association guideline on the treatment of major depressive disorder and the 2014 Guideline Watch, did not mention the use of deep brain stimulation (DBS) for the treatment of major depressive disorder.
National Institute of Health and Care Excellence (NICE)
The National Institute of Health and Care Excellence (NICE) has published Interventional Procedure Guidance documents on deep brain stimulation (DBS):
Tremor and Dystonia: In 2006, NICE made the same statement for use of DBS for treatment of tremor and dystonia. Unilateral and bilateral stimulation of structures responsible for modifying movements, such as the thalamus, globus pallidus, and the subthalamic nucleus, which interact functionally with the substantia nigra, are included in both guidance statements.
Refractory Chronic Pain Syndromes (excluding headache): In 2011 guidance states that there is evidence that DBS is efficacious in some patients who are refractory to other forms of pain control and that this procedure may be used provided normal arrangements are in place for clinical governance, consent and audit. Patients should be informed that DBS may not control their chronic pain symptoms and that possible risk associated with this procedure include small risk of death.
Intractable Trigeminal Autonomic Cephalalgias: In 2011 guidance states that current evidence on the efficacy of DBS for intractable trigeminal autonomic cephalalgias (e.g. cluster headaches) is limited and inconsistent, and the evidence on safety shows that there are serious but well-known adverse effects. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research.
Refractory Epilepsy: In 2012 guidance states that the evidence on the efficacy of the DBS for refractory epilepsy is limited in both quantity and quality. The evidence on safety shows that there are serious but well-known adverse effects. Therefore, the procedure should only be used with special arrangements for clinical governance, consent and audit or research.
Parkinson Disease: In 2003 guidance states current evidence on the safety and efficacy of DBS for treatment of PD appears adequate to support the use of the procedure, provided that normal arrangements are in place for consent, audit, and clinical governance.
Parkinson Disease: In 2006 guidance on the diagnosis and management of PD in primary and secondary care. With the evidence at that time, it was not possible to decide if the subthalamic nucleus or globus pallidus interna is the preferred target for DBS for people with PD, or whether one form of surgery is more effective or safer than the other. Based on level 3 or 4 evidence, NICE concluded that thalamic DBS may be considered an option in people with PD who predominantly have severe disabling tremor and where subthalamic nucleus stimulation cannot be performed.
The U.S. Food and Drug Administration (FDA) has approved the Activa® Tremor Control System, manufactured by Medtronic Corp, MN, for deep brain stimulation. While the original 1997 FDA-labeled indications were limited to unilateral implantation of the device for the treatment of tremor, in January 2002, the FDA-labeled indications were expanded to include bilateral implantation as a treatment to decrease the symptoms of advanced Parkinson’s disease that are not controlled by medication.
In April 2003, the labeled indications were expanded to include “unilateral or bilateral stimulation of the internal globus pallidus or subthalamic nucleus to aid in the management of chronic, intractable (drug refractory) primary dystonia, including generalized and/or segmental dystonia, hemidystonia, and cervical dystonia (torticollis) in patients seven years of age or above.” This latter indication received FDA approval through the Humanitarian Device Exemption process. The Activa Tremor Control System consists of the following components: the implantable pulse generator, the deep brain stimulator lead, an extension that connects the lead to the power source, a console programmer, a software cartridge to set electrical parameters for simulation, and a patient control magnet, which allows the patient to turn the pulse generator on and off, or change between high and low settings.
In February 2009, the FDA approved deep brain stimulation with the Reclaim® device (Medtronic, Inc.) via the Humanitarian Device Exemption (HDE) process for the treatment of severe obsessive-compulsive disorder (OCD).
The Vercise™ Deep Brain Stimulation system (Boston Scientific) is currently available in Europe, Israel,and Australia. Completion of a large U.S. multicenter trial (INTREPID) is expected in 2021.
Unilateral or bilateral deep brain stimulation (DBS) of the globus pallidus (GPi) or the subthalmic nucleus (STN) may be considered medically necessary in patients 7 years of age or older with intractable (drug refractory) primary dystonia, including generalized and/or segmental dystonia, hemidystonia and cervical dystonia (torticollis)
Unilateral or bilateral deep brain stimulation (DBS) of the globus pallidus (GPi) or subthalmic nucleus (STN) may be considered medically necessary in individuals that have moderate to severe medically intractable idiopathic Parkinson’s disease with the following:
- A minimal score of 30 points on the motor portion of the United Parkinson’s Disease Rating Scale (UPDRS) when the individual has been off medication for about 12 hours; and
- A good response to Levodopa; and
- Motor complications that can not be managed with medication; and
- The presence of at least 2 major symptoms of Parkinson’s disease (tremor, rigidity, slowness or movement or impaired balance and coordination)
Unilateral deep brain stimulation (DBS) of the ventral intermediate nucleus of the thalamus (Vim) may be considered medically necessary in patients with disabling medically unresponsive tremor due to essential tremor (ET) or Parkinson disease (PD).
Disabling, medically unresponsive tremor is defined as all of the following:
- Tremor causing significant limitation in daily activities
- inadequate control by maximal dosage of medication for at least 3 month before implant
Based on peer reviewed literature there is insufficient evidence to support the safety and effectiveness of deep brain stimulation (DBS), additional controlled studies with larger number of subjects are required to evaluate the role of DBS for thees conditions and therefore is considered investigational, including but not limited to the following indications:
- Alzheimer’s Disease/dementias
- Chronic pain/Chronic pain syndromes
- Obsessive-compulsive disorder (OCD)
- Cluster headache/headaches
- Tourette Syndrome
- Tardive Dyskinesia
- Multiple sclerosis
- Anorexia nervosa/eating disorders
- Head or voice tremor
- Huntington’s disease
The use of cerebellar stimulation/pacing is considered investigational. Based on peer reviewed literature there is insufficient evidence to support the effectiveness of cerebellar stimulation/pacing on health outcomes and is therefore considered investigational.
United Parkinson’s Disease Rating Scale (UPDRS): UPDRS is a universal scale of Parkinson’s disease (PD) symptoms and it was created to comprehensively assess and document the exam of the patient with PD and be able to compare it with patient’s future follow up visits, or to communicate about the progression of the PD symptoms in each patient with other neurologists.
The UPDRS is made up of the 1) Mentation, Behavior, and Mood, 2) ADL and 3) Motor sections. These are evaluated by interview. Some sections require multiple grades assigned to each extremity. A total of 199 points are possible. 199 represents the worst (total) disability), 0--no disability.
Essential Tremor: Uncontrolled shaking or trembling, usually of one or both hands or arms, that worsens when basic movements are attempted. It is caused by abnormalities in areas of the brain that control movement and is not tied to an underlying disease (e.g. Parkinson’s disease).
Dystonia: Highly variable neurological movement disorder characterized by involuntary muscle contractions. Dystonia results from abnormal functioning of the basal ganglia, a deep part of the brain which helps control coordination of movement. These regions of the brain control the speed and fluidity of movement and prevent unwanted movements. Patients with dystonia may experience uncontrollable twisting, repetitive movements, or abnormal postures and positions. These can affect any part of the body, including the arms, legs, trunk, face and vocal cords. Dystonia can affect young children to older adults of all races and ethnicities.
- Primary (Idiopathic) Dystonia: Dystonia is the only sign, and secondary causes have been ruled out. Most primary dystonias are variable, have adult onset, and are focal or segmental in nature. However, there are specific primary dystonias with childhood or adolescent onset that have been linked to genetic mutations.
- Focal Dystonia: Is limited to one area of the body.
- Segmental Dystonia: Affects two or more parts of the body that are adjacent or close to one another.
Idopathic Parkinson’s Disease: Most common form of Parkinson’s disease, and the cause essentially remains unknown. Parkinson’s disease is a progressive disorder that is caused by a degeneration of nerve cells in the part of the brain called the substantia nigra, which controls movement. These nerve cells die or become impaired, losing the ability to produce an important chemical called dopamine.
Secondary Parkinsonism: This is a disorder with symptoms similar to Parkinson’s, but is caused by medication side effects, different neurodegenerative disorders, Illness, or brain damage.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
- 61863 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalmic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array
- 61864 each additional array
- 61867 Twist drill, burr hole, craniotomy, or cranietctomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalmic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array
- 61868 each additional array
- 61870 Craniectomy for implantation of neurostimulator electrodes, cerebellar, cortical
- 61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array
- 61886 With connection to 2 or more electrode arrays
- C1767 Generator neurostimulator (implantable) non-rechargeable
- C1778 Lead, nuerostimulator
- C1787 Patient programmer, neurostimulator
- C1816 Receiver and/or transmitter neurostimulator (implantable)
- C1820 Generator neurostimulator (implantable, with rechargeable battery and charging system)
- 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
- L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
- L8685 Implantable neurostimulator pulse generator, single array, rechargeable includes extension
- L8686 Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension
- L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
- L8688 Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension
- L8689 External recharging system for battery (internal)for use with implantable neurostimulator, replacement only
- 95970 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode slectability, output modulation, cycling impedance and patient compliance measurements); simple or complex brain, spinal cord or peripheral (i.e. cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter without reprogramming
- 95978 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polatiry, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour
- 95979 each additional 30 minutes after first house (list separately in addition to code for primary procedure
Wellmark's policy is based on:
- ECRI Institute. Deep Brain Stimulation for Treating Non-Parkinsonian Neurologic and Psychiatric Disorders. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2012 November. [Hotline Response].
- Department of Health and Human Services Food and Drug Administration, Humanitarian Device Exemption for Medtronic Activa Dystonia Therapy, for the management of chronic, intractable (drug refractory) primary dystonia. April 2003.
- American Academy of Neurology. Practice Parameter: Therapies for Essential Tremor: Report of the Quality Standards Subcommittee of the American Academy of Neurology. T.A. Zesiewicz, R. Elble, E.D. Louis, et. Al. Neurology 2005; 64; 2008-2020. Published online before print June 22, 2005. DOI 10.1212/01.WNL.0000163769.28552.CD.
- American Academy of Neurology. Practice Parameter of Parkinson Disease with Motor Fluctuations and Dyskinesia (an evidence based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. R. Pahwa, S.A. Factor, K. E. Lyons, et al. Neurology 2006; 66;983-995 Published online before print April 2, 2006. DOI 10.1212/01. WNL.0000215250.82576.87
- American Academy of Neurology. Evidence Based Guideline: Treatment of Tadive Syndromes: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Roongroj Bhidayasiri, Stanley Fahn, William J. Weinter, et al. Neurology 2013; 81; 463-469. DOI 10.1212/WNL.0b013e31829d86b6.
- Deep Brain Stimulation for Primary Generalized Dystonia. Ioaanis U. Isaias, M.D., Ron L. Alterman, M.D., Michele Tagliati, M.D. Jama Neurology. Vol 66 (NO4), April 2009. Available at: www.archneur.jamanetwork.com
- American Association of Neurological Surgeons (AANS). Patient Information. Deep Brain Stimulation. April 2007.
- American Association of Neurological Surgeons (AANS). Patient Information. Dystonia. October 2005.
- American Association of Neurological Surgeons (AANS): Patient Information. Movement Disorders. January 2013.
- American Association of Neurological Surgeons (AANS): Patient Information. Parkinson's Disease. December 2005.
- American Society for Stereotactic and Functional Neurosurgery. Deep Brain Stimulation: Indications, Techniques, and Practice Parameters.
- Medtronic. Deep Brain Stimulation.
- PubMed. Deep Brain Stimulation for Psychiatric Disorders. 2010 Feb; 107(7):105-13. Kuhn J, Grundler TO, Lenartz D, Sturm V, Klosterkotter J, Huff W.
- PubMed. Pallidal Deep Brain Stimulation for Primary Dystonia in Children. Neurosurgery 2011 Mar; 68(3): 738-43. Haridas A, Tagliati M, Osborn I, Isaias I, Gologorsky Y, Bressman SB, Weisz D, Alterman RL.
- MedScape. Deep Brain Stimulation for Parkinson's Disease and Other Movement Disorders. Curr Opin Neurol. 2013; 26 (4): 374-380. Suneil K. Kalia, Tejas Sankar, Andres M. Lazano.
- The Medical Letter, On Drugs and Therapeutics. Volume 55 (Issue 1427), October 14, 2013. Deep Brain Stimulation for Parkson's Disease with Early Motor Complications.
- ECRI. Health Technology Forecast. Deep Brain Stimulation for Treatment-Resistant Depression. May 2011.
- ECRI. Health Technology Forecast. Deep Brain Stimulation for Treatment Resistant Obsessive Compulsive Disorder. September 2013.
- ECRI Institute. Deep Brain Stimulation for Primary Dystonia. September 2010.
- UpToDate. Surgical Treatment of Essential Tremor. Daniel Tarsy, M.D.. Topic Last Updated: March 11, 2015.
- UpToDate. Cluster Headache: Acute and Preventative Treatment. Arne May, M.D.. Topic Last Updated October 16, 2014.
- UpToDate.Deep Brain Stimulation for Treatment of Obsessive Compulsive Disorder. Damiaan Denys, M.D., PhD, Pelle P. de Koning, M.D.. Topic Last Updated May 15, 2015.
- UpToDate. Tourette Syndrome. Joseph Jankovic, M.D.. Topic Last Updated August 27, 2015.
- UpToDate.Tardive Dyskinesia: Preventative and Treatment. Daniel Tarsy, M.D.. Topic Last Updated June 3, 2015.
- UpToDate. Unipolar Depression in Adults: Treatment with Surgical Appraches. Paul E. Holtzheimer, M.D.. Topic Last Updated August 13, 2015.
- American Psychiatric Association. Practice Guideline for the Treatment of Patients with Obsessive Compulsive Disorder. Approved October 2006 and published July 2007.
- CMS. National Coverage Determination (NCD) for Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease. Available at www.cms.gov
- National Institute of Health and Clinical Excellence (NICE), Deep Brain Stimulation for Refractory Epilepsy: Clinical Audit Tool.
- UpToDate. Surgical Treatment of Parkinson Disease. Daniel Tarsey M.D.. Topic last updated May 9, 2014. Also available www.uptodate.com
- UpToDate. Treatment of Dystonia. Cynthia Comella, M.D.. Topic last updated June 9, 2015. Also available www.uptodate.com
- UpToDate. Overview of Chronic Daily Headache. Also available at www.uptodate.com
- UpToDate. Short Lasting Unilateral Neuralgiform Headache Attacks. Treatment. Manjit S. Matharu, M.D., Anna S. Cohen, M.D.. Topic last updated December 5, 2013. Also available at www.uptodate.com
- UpToDate. Eating Disorders. Overview and Treatment. Sara F. Foreman, M.D.. Topic last updated August, 2015. Also available at www.uptodate.com
- UpToDate. Evaluation and Management of Drug Resistant Epilepsy. Joseph I Sirven, M.D.. Topic last updated May 15, 2014. Also available at www.uptodate.com
- UpToDate. Huntington Disease: Management. Oksana Suchowersky, M.D., FRCPC, FCCMG. Topic last updated September 16, 2014 Also available at www.uptodate.com
- UpToDate. Overview of the Treatment of Chronic Pain. Ellen WK Rosenquist M.D.. Topic last updated August 17, 2015. Also available at www.uptodate.com
- Medscape. Deep Brain Stimulation in Treatment Resistant Depression. www.medscape.com
- UpToDate. Depression in Adults Overview of Neuromodulation Porcedures, Paul E. Holtzheimer, M.D.. Topic last updated August 13, 2015. Also available at www.uptodate.com
- Koran Lorrin and Simpson Blair H, American Psychiatric Association Guideline Watch (March 2013) Practice Guideline for the Treatment of Patients with Obsessive Compulsive Disorder. Also available at http://psychiatryonline
- Bhidayasiri Roongroj, Fahn Stanley, et. al. Evidence Based Guideline: Treatment of Tardive Syndromes, American Academy of Neurology, Neurology July 320, 2013 Vol 81 No 5 463-469
- National Institute of Health and Care Excelleence (NICE) Interventional Procedure Guidance 19. Deep Brain Stimulation for Parkinsons Disease 2003. Also available at www.nice.org
- National Institute of Health and Care Excellence (NICE). Interventional Procedure Guidance 188. Deep Brain Stimulation for Tremor and Dystonia (excluding Parkinson Disease). 2006. Also available at www.nice.org
- National Institute of Health and Care Excellence (NICE). Interventional Procedure Guidance 382. Deep Brain Stimulation for Refractory Chronic Pain Syndromes (excluding headache) 2011. Also available at www.nice.org
- National Institute of Health and Care Excellence (NICE) Interventional Procedure Guidance 381. Deep Brain Stimulation for Intractable Trigeminal Autonomic Cephalalgias 2011 Also available at www.nice.org
Date Reason Action
October 2010 Annual review Policy renewed
February 2011 Interim review Policy revised
January 2012 Annual review Policy renewed
January 2013 Annual review Policy renewed
January 2014 Annual eeview Revised and New Policy Created
October 2014 Annual review Policy revised
February 2015 Policy revised
September 2015 Annual review Policy revised
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.