MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
ANTHEM-MED.00057
This policy addresses MRI-guided high-intensity focused ultrasound (MRgFUS) ablation for non-oncologic indications, including unilateral thalamotomy/pallidotomy. Coverage is limited to unilateral MRgFUS thalamotomy for adults with essential tremor who have moderate-to-severe hand tremor (CRST ≥2) and have failed at least two tremor-suppressant medications (one being propranolol or primidone) due to persistent symptoms, intolerable side effects, or contraindications. Unilateral MRgFUS thalamotomy that does not meet these criteria, unilateral MRgFUS pallidotomy, bilateral staged MRgFUS thalamotomy or pallidotomy, and all other non-oncologic uses (e.g., benign prostatic hyperplasia, uterine fibroids) are investigational and not medically necessary.
"Unilateral focused ultrasound thalamotomy is consideredmedically necessaryfor the treatment of adults with essential tremors whenallof the following criteria are met:Moderate to severe tremor of th..."