About this policy
Jurisdiction: JE Part B. States: California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands. Type: Active LCD
Coverage indications
This LCD addresses use of Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for the treatment of idiopathic essential tremor (ET) patients including Tremor Dominant Parkinson's disease (TDPD) patients with medication-refractory tremor. MRgFUS unilateral thalamotomy is considered medically reasonable and necessary in patients with all four of the following criteria: medication refractory ET (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 dominant hand or another nationally accepted clinical measure of tremor severity disabling ET (defined by a score of ≥2 on any of the eight items in the disability subsection of the CRST or another nationally accepted clinical measure of tremor severity) not a candidate for DBS (e.g., advanced age, anticoagulant therapy, surgical comorbidities, or has failed Deep Brain Stimulation (DBS), but has no retained cranial implants) Limitations (not covered): Treatment of head or voice tremor Bilateral thalamotomy An advanced neurodegenerative condition Unstable cardiac disease Depression sufficiently severe to compromise beneficiary’s ability to provide informed consent and limit likely clinical benefit of the treatment Severe cognitive impairment (such as may be defined by a score of A skull density ratio (SDR) (the ratio of cortical to cancellous bone) MRI contraindicated
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.