61889
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
25.11
Facility
$1750.21
Non-Facility
$1750.21
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.
- Clinical documentation confirming patient age (≥18) and diagnosis of focal epilepsy.
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
- Refractory to two (2) or more antiepileptic medications;and
10 Active Policies
UMR-POL-UMR-deep-brain-cortical-stimulation — Deep Brain and Cortical Stimulation
SUREST-POL-SUREST-deep-brain-cortical-stimulation — Deep Brain and Cortical Stimulation
UHC-POL-deep-brain-cortical-stimulation — Deep Brain and Cortical Stimulation
ANTHEM-SURG.00026 — SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
BCBSIL-SUR712.039
Related Codes
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