61850
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
13.01
Facility
$990.00
Non-Facility
$990.00
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews.
- For medical necessity clinical coverage criteria for deep brain and responsive cortical stimulation, refer to the InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes.
- When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs.
- Trigeminal/occipital radiofrequency or nerve ablation/neurectomy: documentation of diagnostic nerve blocks demonstrating temporary relief, prior conservative treatments attempted and failed, technique details, and baseline/ongoing outcome measures.
Key Coverage Criteria
- Deep brain stimulation is proven and medically necessary for treating the following indications: Dystonia
- Deep brain stimulation is proven and medically necessary for treating the following indications: Essential tremor
- Deep brain stimulation is proven and medically necessary for treating the following indications: Parkinson's disease
- Deep brain stimulation is proven and medically necessary for treating the following indications: Refractory epilepsy for a partial or focal seizure disorder
- Responsive cortical stimulation is proven and medically necessary for treating refractory partial or focal seizure disorder
- Temporal artery biopsy — CPT 37609: "Ligation or biopsy, temporal artery [covered for biopsy to rule out temporal arteritis]" (ICD-10: M31.6 Other giant cell arteritis [suspected temporal arteritis] listed as an ICD-10 code covered if selection criteria are met).
15 Active Policies
AETNA-CPB-0374 — Trigeminal Neuralgia: Treatments
AETNA-CPB-0406 — Tinnitus Treatments
AETNA-CPB-0755 — Motor Cortex Stimulation
UMR-POL-UMR-deep-brain-cortical-stimulation — Deep Brain and Cortical Stimulation
SUREST-POL-SUREST-deep-brain-cortical-stimulation — Deep Brain and Cortical Stimulation
Related Codes
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