LCD/NCD Portal

NCD160.24

 

DEEP BRAIN STIMULATION FOR ESSENTIAL TREMOR AND PARKINSON’S DISEASE

 

 

Effective Date of this Version

4/1/2003

 

Benefit Category

• Physicians' Services.

• Prosthetic Devices.

• Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

 

Indications and Limitations of Coverage

• Effective for services furnished on or after April 1, 2003, Medicare will cover unilateral or bilateral thalamic ventralis intermedius nucleus (VIM) deep brain stimulation (DBS) for the treatment of essential tremor (ET) and/or Parkinsonian tremor and unilateral or bilateral subthalamic nucleus (STN) or globus pallidus interna (GPi) DBS for the treatment of Parkinson's disease (PD) only under the following conditions:

o Medicare will only consider DBS devices to be reasonable and necessary if they are Food and Drug Administration (FDA) approved devices for DBS or devices used in accordance with FDA approved protocols governing Category B Investigational Device Exemption (IDE) DBS clinical trials.

o For thalamic VIM DBS to be considered reasonable and necessary, patients must meet all of the following criteria:

 Diagnosis of ET based on postural or kinetic tremors of hand(s) without other neurologic signs, or diagnosis of idiopathic PD (presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia)) which is of a tremor-dominant form.

 Marked disabling tremor of at least level 3 or 4 on the Fahn-Tolosa-Marin Clinical Tremor Rating Scale (or equivalent scale) in the extremity intended for treatment, causing significant limitation in daily activities despite optimal medical therapy.

 Willingness and ability to cooperate during conscious operative procedure, as well as during post-surgical evaluations, adjustments of medications and stimulator settings.

o For STN or GPi DBS to be considered reasonable and necessary, patients must meet all of the following criteria:

 Diagnosis of PD based on the presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia).

 Advanced idiopathic PD as determined by the use of Hoehn and Yahr stage or Unified Parkinson's Disease Rating Scale (UPDRS) part III motor subscale.

 L-dopa responsive with clearly defined "on" periods.

 Persistent disabling Parkinson's symptoms or drug side effects (e.g., dyskinesias, motor fluctuations, or disabling "off" periods) despite optimal medical therapy.

 Willingness and ability to cooperate during conscious operative procedure, as well as during post-surgical evaluations, adjustments of medications and stimulator settings.

• DBS is not reasonable and necessary and is NOT covered for ET or PD patients with any of the following:

o Non-idiopathic Parkinson's disease or "Parkinson's Plus" syndromes.

o Cognitive impairment, dementia or depression, which would be worsened by or would interfere with the patient's ability to benefit from DBS.

o Current psychosis, alcohol abuse or other drug abuse.

o Structural lesions such as basal ganglionic stroke, tumor or vascular malformation as etiology of the movement disorder.

o Previous movement disorder surgery within the affected basal ganglion.

o Significant medical, surgical, neurologic or orthopedic co-morbidities contraindicating DBS surgery or stimulation.

• Patients who undergo DBS implantation should not be exposed to diathermy (deep heat treatment including shortwave diathermy, microwave diathermy and ultrasound diathermy) or any type of MRI, which may adversely affect the DBS system or adversely affect the brain around the implanted electrodes.

• DBS should be performed with extreme caution in patients with cardiac pacemakers or other electronically controlled implants, which may adversely affect or be affected by the DBS system.

• For DBS lead implantation to be considered reasonable and necessary, providers and facilities must meet all of the following criteria:

o Neurosurgeons must:

 Be properly trained in the procedure.

 Have experience with the surgical management of movement disorders, including DBS therapy.

 Have experience performing stereotactic neurosurgical procedures.

o Operative teams must have training and experience with DBS systems, including knowledge of anatomical and neurophysiological characteristics for localizing the targeted nucleus, surgical and/or implantation techniques for the DBS system, and operational and functional characteristics of the device.

o Physicians specializing in movement disorders must be involved in both patient selection and post-procedure care.

o Hospital medical centers must have:

 Brain imaging equipment (MRI and/or CT) for pre-operative stereotactic localization and targeting of the surgical site(s).

 Operating rooms with all necessary equipment for stereotactic surgery.

 Support services necessary for care of patients undergoing this procedure and any potential complications arising intraoperatively or postoperatively.

 

Claims Processing Instructions

• TN AB-03-023 (Program Memorandum Intermediaries/Carriers)

• TN 128 (Medicare Claims Processing)

 

Coverage Transmittal Link

• http://www.cms.gov/transmittals/downloads/R167CIM.pdf

 

National Coverage Analyses (NCAs)

• This NCD has been or is currently being reviewed under the National Coverage Determination process.

• The following are existing associations with NCAs, from the National Coverage Analyses database.

• Original consideration for Deep Brain Stimulation for Parkinson's Disease (CAG-00124N)

 

 

Medicare NCD Link