CurrentAetnaPolicy 0401

Selective Peripheral Denervation (Bertrand Procedure)

Defines Aetna's medical necessity and investigational criteria for selective peripheral denervation (Bertrand procedure) for treatment of spasmodic torticollis (cervical dystonia), lists related and non-covered procedures, and provides applicable CPT/HCPCS/ICD-10 codes and background evidence.

Policy Summary

PayerAetna

PolicySelective Peripheral Denervation (Bertrand Procedure)

Policy CodePolicy 0401

Change TypeNo material change

Effective DateMar 7, 2000

Next Review DateApr 25, 2024

Key ActionProvider must document that current spasmodic torticollis symptoms are disabling and document failure/intolerance of appropriate pharmacotherapies or resistance to botulinum toxin A or B before SPD is considered medically necessary.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Covered ICD-10 indication (G24.3)

2Procedures experimental/investigational

3Related CPT/HCPCS/J-codes listed

Coverage Summary

Scope: Defines Aetna's medical necessity and investigational criteria for Selective Peripheral Denervation (Bertrand procedure) for treatment of spasmodic torticollis (cervical dystonia), lists related and non-covered procedures, and provides applicable CPT/HCPCS/ICD-10 codes and background evidence. Policy number: 0401. Coverage stance: mixed.

Medical-Necessity Criteria

Medically Necessary

Aetna considers selective peripheral denervation (Bertrand procedure) medically necessary when ALL of the following are met:

Medically Necessary - All criteria must be met

Disabling symptoms: Current symptoms are disabling
Failed medical management: Member has failed an appropriate course of pharmacotherapies or has had adverse side effects from the medications or the member has developed resistance to botulinum toxin type A or type B

Documentation Required

Documentation of disabling symptoms

Document in the medical record that the member's current spasmodic torticollis symptoms are disabling (required to meet medical necessity).

Aetna requirement: disabling symptoms documented in record

Documentation Required

Documentation of prior medical management failure or intolerance

Document that the member failed an appropriate course of pharmacotherapies or experienced adverse side effects from medications, or developed resistance to botulinum toxin type A or B (J0585/J0587) or had prior chemodenervation of neck muscles (64616).

J0585
J0587
64616

Experimental and Investigational / Not Medically Necessary

Experimental and Investigational (Not Medically Necessary)

Selective peripheral denervation is considered experimental and investigational when the medically necessary criteria are not met. Additionally, the following specific procedures are considered experimental and investigational:

Experimental/Investigational - Any of the following

Combined SPD and DBS: Combined selective peripheral denervation and deep brain stimulation for the treatment of spasmodic torticollis
Selective peripheral neurectomy - upper limb: Selective peripheral neurectomy for the treatment of upper limb spasticity
SPD without disability or failed medical management: Selective peripheral denervation for persons without disability or who have not failed medical management (value unproven)

Selective peripheral denervation (SPD) is considered experimental and investigational when the policy's medically necessary criteria are not met. The policy states the value of SPD is unproven in persons without disability or in persons who have not failed medical management, and SPD is investigational when selection criteria are not satisfied.

Examples of procedures specifically listed as experimental and investigational include: combined selective peripheral denervation and deep brain stimulation for spasmodic torticollis and selective peripheral neurectomy for the treatment of upper limb spasticity.

Coding

Relevant CPT codes (related procedures)CPT

64616	Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis)
64640	Destruction by neurolytic agent; other peripheral nerve or branch

HCPCS / J-codes (botulinum toxins referenced)HCPCS

J0585	Botulinum toxin type A, per unit
J0587	Botulinum toxin type B, per 100 units

Procedure code for Selective Peripheral Denervation (no specific CPT)mixed

No specific code

Selective Peripheral Denervation (Bertrand Procedure) for Spasmodic Torticollis — no specific CPT code listed

ICD-10 codes covered if selection criteria are metICD-10Covered

G24.3

Spasmodic torticollis [severe, disabling]

ICD-10 codes not covered for indications listed in the CPBICD-10Not Covered

G80.1

Spastic diplegic cerebral palsy [upper limb spasticity]

Background & Evidence

Background: Spasmodic torticollis (cervical dystonia) is a focal dystonia in which neck muscles contract involuntarily, causing abnormal head/neck posture and pain; botulinum toxin injections improve symptoms in many patients. Selective peripheral denervation removes nerve supply to selected hyperactive muscles while preserving innervation to uninvolved muscles and may benefit patients with disabling cervical dystonia refractory to medical therapy.

Guideline context: An EFNS/MDS-ES Task Force concluded that SPD is a safe procedure indicated exclusively in cervical dystonia and that the procedure requires specialized expertise. NICE guidance concluded evidence is adequate to support SPD provided normal arrangements for consent, audit and clinical governance and that SPD should be reserved for disease refractory to best medical treatment (including physiotherapy, antispasmodic drugs, and botulinum toxin injections).

Indications and expertise: SPD is intended for patients with disabling spasmodic torticollis who have failed appropriate pharmacotherapies or have adverse effects or resistance to botulinum toxin; patient selection and performance by clinicians with specialized expertise are emphasized.

Citation	Key findings
Wang et al. 2015 cohort (648 pts)
Mean TWSTRS decreased from 54.7 to 31.1; clinical improvement 73.5% ±11.9%; no deaths or serious complications reported
EFNS/MDS-ES Task Force (Albanese et al., 2006)
Concluded SPD is a safe procedure with infrequent/minimal side effects; indicated exclusively in cervical dystonia and requires specialized expertise
NICE Guidance (2004)
Concluded evidence adequate to support SPD provided normal arrangements for consent, audit and clinical governance; reserved for disease refractory to best medical treatment and importance of careful patient selection
Selective peripheral neurectomy evidence (Yong et al., 2018)
Only case series reported (no RCTs); heterogeneous techniques and high risk of bias — insufficient evidence to draw firm conclusions for upper limb spasticity

Provider Actions

Documentation Required

Required Documentation

To meet medical necessity, document that symptoms are disabling and that appropriate medical management has failed or was not tolerated, including pharmacotherapy adverse effects or botulinum toxin resistance.

Prior medications tried and treatment dates
Adverse effects or intolerance to medications
Evidence of botulinum toxin resistance or prior response (J0585, J0587)
Prior chemodenervation procedure codes (e.g., 64616)

Note

Specialized Expertise Recommended

Guidance and evidence recommend that selective peripheral denervation be performed by clinicians with specialized expertise and within normal arrangements for consent, audit, and clinical governance (per EFNS/MDS-ES and NICE).

Policy Summary

PayerAetna

PolicySelective Peripheral Denervation (Bertrand Procedure)

Policy CodePolicy 0401

Change TypeNo material change

Effective DateMar 7, 2000

Next Review DateApr 25, 2024

SourceLink

On This Page

OpenPayer

Selective Peripheral Denervation (Bertrand Procedure)

Coverage Summary

Medical-Necessity Criteria

Experimental and Investigational / Not Medically Necessary

Coding

Background & Evidence

Provider Actions

Revision History