CG-SURG-108 Stereotactic Radiofrequency Pallidotomy

This policy addresses stereotactic radiofrequency pallidotomy with microelectrode mapping (unilateral) for Parkinson’s disease. It is covered only when all criteria are met: confirmed idiopathic Parkinson’s disease (secondary/atypical parkinsonism ruled out), severe levodopa-induced dyskinesia or severe bradykinesia/dystonia/akinesia–rigidity or marked on–off fluctuations, no history of encephalitis or neuroleptic treatment, and no dementia or focal brain abnormality on MRI. It is not covered when these criteria are unmet, for any bilateral pallidotomy, or for other indications not specified.

"Unilateral stereotactic radiofrequency pallidotomy with microelectrode mapping is consideredmedically necessaryfor individuals who meetallof the following criteria:"

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