Deep Brain Stimulation (DBS)

This policy covers deep brain stimulation (DBS) services—including stereotactic electrode placement, short-term stimulation trials, and implantation of implantable neurostimulator systems (e.g., Activa)—for treatment of disabling, medically refractory tremor, Parkinson disease, and primary dystonia. Covered populations include patients with essential tremor or Parkinson disease (unilateral or bilateral thalamic DBS for tremor; globus pallidus or subthalamic nucleus DBS for Parkinson’s in those with good levodopa response, motor UPDRS ≥30 off meds, and ≥4 years’ disease duration) and patients aged ≥7 years with drug‑refractory primary dystonia; major limitations require meeting these clinical criteria, exclude DBS for other neurologic or psychiatric indications (investigational), and contraindicate use in poor surgical candidates, those requiring repeated MRI, or recent botulinum toxin treatment, with recommended presurgical suicide‑risk assessment.

"Unilateral thalamic DBS for disabling, medically unresponsive tremor due to essential tremor or Parkinson disease."