About this policy
Jurisdiction: J6 MAC Part B. States: Illinois, Minnesota, Wisconsin. Type: Active LCD
Coverage indications
This LCD addresses use of Magnetic Resonance Guided Focused Ultrasound Surgery System (MRgFUS) for the treatment of neurologic conditions. MRgFUS unilateral thalamotomy is considered medically reasonable and necessary in patients with all of the following: Medication refractory (ONE) Essential Tremor (ET) - defined as refractory to at least two trials of medical therapy, including at least one first-line agent Tremor-Dominant Parkinson's disease (TDPD) (BOTH) refractory (or intolerant) to levodopa or levodopa equivalent daily dosage (LEDD) ≥ 900 mg On-medication Unified Parkinson’s Disease Rating Scale (UPDRS) ratio of the mean score for tremor items (items 16, 20, and 21) to the mean postural instability/gait disorder score (items 13-15, 29, and 30) of ≥ 1.5 Moderate to severe postural or intention tremor of the hand (defined by a score of ≥2 on the Clinical Rating Scale for Tremor (CRST) Disabling Tremor (defined by a score of ≥2 on any of the eight items in the disability subsection of the CRST) Not a surgical candidate for DBS (e.g., advanced age, anticoagulant therapy, or surgical comorbidities) MRgFUS Bilateral thalamotomy for Essential Tremor as a staged procedure by at least 9 months from the first thalamotomy is considered medically reasonable and necessary in patients with all of the following : Medication refractory defined as refractory to at least two trials of medical therapy, including at least one first-line agent Moderate to severe postural or intention tremor of the hand (defined by a score of ≥2 on the Clinical Rating Scale for Tremor (CRST) Disabling Tremor (defined by a score of ≥2 on any of the eight items in the disability subsection of the CRST) Not a surgical candidate for DBS (e.g., advanced age, anticoagulant therapy, or surgical comorbidities) MRgFUS Unilateral pallidotomy is considered medically necessary for the treatment of idiopathic Parkinson’s disease in individuals who meet all of the following criteria: Age 30 or older; and Unilateral pallidotomy is used as an adjunct to medication treatment of idiopathic Parkinson’s disease; and Levodopa responsive (as defined by a 30% or greater reduction in the Movement Disorder Society- Unified Parkinson's Disease Rating Scale [MDS-UPDRS] motor subscale in the on versus off levodopa medication state; and Moderate-to-severe motor complications as defined by at least one of the following: MDS-UPDRS score of 20 or greater in the meds off condition; or Motor complications on optimum medical treatment documented by at least one of the following: Dyskinesia (as defined by MDS-UPDRS item 4.2 score of 2 or greater in the meds on condition); or Motor fluctuations (as defined by MDS-UPDRS item 4.4 score of 2 or greater); and The individual is not a candidate for either of the following procedures: Deep brain stimulation (DBS); or Radiofrequency (RF) thermoablation; and The absence of all of the following conditions: Central neurodegenerative disease other than Parkinson’s Disease (includes multisystem atrophy, progressive supranuclear palsy, corticobasal syndrome, dementia with Lewy bodies, and Alzheimer’s disease); or Previous deep brain stimulation; or Previous basal ganglia ablation procedure; or Coagulopathy or current anticoagulant use which cannot be reversed; or Intracranial tumor with significant anatomic distortion. Limitations (not covered): Treatment of head or voice tremor Bilateral thalamotomy for Parkinson's Disease Conditions other neurodegenerative condition unstable cardiac disease untreated coagulopathy risk factors for deep-vein thrombosis severe depression (defined by a score ≥20 on Patient Health Questionnaire 9 (PHQ-9) or Beck Depression Inventory score (BDI-II) >14) cognitive impairment (defined by a score of previous brain procedure (transcranial magnetic stimulation, DBS, stereotactic lesioning, or electroconvulsive therapy) a skull density ratio (of cortical to cancellous bone) MRI contraindicated Drug-induced Parkinsonism history of seizures, brain tumor, intracranial aneurysm or arteriovenous malformation requiring treatment pregnancy
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.