61891
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
10.97
Facility
$837.36
Non-Facility
$837.36
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.
- No explicit documentation requirements are stated in the provided text.
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
- Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Tremor (LCD L37421 / A57435) — listed as an LCD/LCA in the document.
11 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
HUMANA-BRAIN-STIMULATION-TREATMENTS-MA — Brain Stimulation Treatments - Medicare Advantage
UHC-POL-deep-brain-cortical-stimulation — Deep Brain and Cortical Stimulation
Related Codes
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