OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentAlliance HealthPolicy 1A-26

Deep Brain Stimulation (DBS)

Customize your policy alerts

Sign up for Alliance Health Policy 1A-26 alerts

Get alerted when Policy 1A-26 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines North Carolina Medicaid coverage, requirements, and limitations for deep brain stimulation (DBS) procedures for enrolled beneficiaries and providers.

Policy Summary

PayerAlliance Health

PolicyDeep Brain Stimulation (DBS)

Policy CodePolicy 1A-26

Change TypeNo material change

Effective DateApr 1, 2024

Last ReviewApr 1, 2024

Next Review DateN/A

Key ActionDocument screening, evaluation, diagnosis, and that all other therapies were tried and found unsatisfactory or unsuitable before implantation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medically necessaryCoverage stance

Case-by-caseHDE handling

AppliesEPSDT (<21)

Not requiredPrior auth

~30ICD-10 codes

~20CPT/HCPCS codes

Coverage Criteria for Deep Brain Stimulation

Specific Criteria Covered (Initial Coverage)

Placement of a deep brain stimulator is covered when ALL of the following are met:

General medical necessity: Procedure is individualized, specific, consistent with symptoms or confirmed diagnosis, and not in excess of beneficiary's needs

Section 3.1 a

Safety and alternatives: Procedure can be safely furnished and no equally effective and more conservative or less costly treatment is available statewide

Section 3.1 b

Not for convenience: Procedure is not primarily for convenience of beneficiary, caretaker, or provider

Section 3.1 c

Policy Summary

PayerAlliance Health

PolicyDeep Brain Stimulation (DBS)

Policy CodePolicy 1A-26

Change TypeNo material change

Effective DateApr 1, 2024

Last ReviewApr 1, 2024

Next Review DateN/A

Key ActionDocument screening, evaluation, diagnosis, and that all other therapies were tried and found unsatisfactory or unsuitable before implantation.

SourceLink

On This Page

Diagnosis requirement:

Beneficiary has one of the diagnoses listed in Attachment A, Claims-Related Information

Pre-implant evaluation: Beneficiary has undergone careful screening, evaluation, and diagnosis prior to implantation

Section 3.2.1 b

Exhaustion of other therapies: All other treatment modalities (pharmacological, surgical, physical, or psychological) have been tried and proven unsatisfactory or are unsuitable/contraindicated

Section 3.2.1 c

Facility and personnel requirements: Required facilities, equipment, and professional and support personnel for proper treatment, training, and follow-up are available

Section 3.2.1 d

HDE / Other Indications

Use of DBS with a Humanitarian Device Exemption (HDE) or for other indications:

HDE/extraordinary: Use of DBS with a Humanitarian Device Exemption (HDE) or for other indications will be considered on a case-by-case basis under extraordinary circumstances

Section 3.2.1 lead-in

General Criteria Not Covered

Medicaid shall not cover the procedure, product, or service when ANY of the following are true:

General Not Covered Conditions: a. Beneficiary does not meet the eligibility requirements listed in Section 2.0; b. Beneficiary does not meet the criteria listed in Section 3.0; c. The procedure, product, or service duplicates another provider's procedure, product, or service; d. The procedure, product, or service is experimental, investigational, or part of a clinical trial.

Section 4.1

Specific Contraindications Not Covered

DBS is contraindicated (not covered) when ANY of the following are present:

DBS Contraindications: a. Medical, surgical, neurologic, or orthopedic co-morbidities exist that contraindicate DBS surgery or stimulation; b. One or more conditions require repeated magnetic resonance imaging (MRI) (MRI can be performed under specialized protocols but repeated MRI requirement is a contraindication); c. Cognitive impairment, dementia, or depression would be worsened by or interfere with the beneficiary's ability to benefit from DBS; d. Botulinum toxin injections have been given within the last 4 months; e. Diathermy will be used in the future.

Section 4.2.1

Services are not covered when any of the following apply: the beneficiary does not meet the eligibility requirements in Section 2.0; the beneficiary does not meet the clinical criteria in Section 3.0; the procedure, product, or service duplicates another provider's procedure, product, or service; or the procedure, product, or service is experimental, investigational, or part of a clinical trial.

No additional, separate exclusions beyond the contraindications listed in Section 4.2.1 are applied. The policy explicitly states that none apply in the Medicaid Additional Criteria Not Covered subsection, meaning coverage exclusions are limited to the contraindications described in Section 4.2.1.

When no specific CPT or HCPCS code exists for a procedure or service, providers must report the service using the appropriate unlisted procedure code and comply with CPT/HCPCS instructions for Unlisted Procedure or Service and Special Report as documented in the current codebooks in effect at the time of service.

Deep brain stimulation is not covered when provided as part of an experimental protocol, investigational use, or within a clinical trial. Services meeting any of these descriptions are excluded from coverage under this policy.

Services that are experimental or investigational, duplicate another provider's service, or are furnished to beneficiaries who do not meet Section 2.0 eligibility or the documented clinical criteria in Section 3.0 are considered not medically necessary and are not covered.

Diagnosis and Procedure Coding

Covered Diagnoses (Attachment A)ICD-10Covered

See Attachment A

Diagnoses eligible for DBS are listed in Attachment A (Claims-Related Information).

ICD-10 Diagnosis CodesICD-10

G20
G20A
G20A1
G20A2
G20B
G20B1
G20B2
G20C
G21.11
G21.19

1–10 of 31

1/4

CPT/HCPCS Codes (Attachment A groups 1-3)CPT

61850
61860
61863
+61864
61867
+61868
61870
61880
61885
61886

1–10 of 22

1/3

ICD-10-CM/PCS CodesICD-10

G20	G20 (listed in document)
G20A	G20A (listed in document)
G20A1	G20A1 (listed in document)
G20A2	G20A2 (listed in document)
G20B	G20B (listed in document)
G20B1	G20B1 (listed in document)
G20B2	G20B2 (listed in document)
G20C	G20C (listed in document)
G21.11	G21.11 (listed in document)
G21.19	G21.19 (listed in document)

1–10 of 31

1/4

CPT/HCPCS CodesCPT

61850	61850
61860	61860
61863	61863
+61864	+61864
61867	61867
+61868	+61868
61870	61870
61880	61880
61885	61885
61886	61886

1–10 of 22

1/3

Botulinum toxin interval — inv-15

Botulinum toxin intervalNo botulinum toxin injections within the last 4 months

Related contraindicationDBS is contraindicated when botulinum toxin injections have been given within the last 4 months (see specific contraindications).

Action for providersVerify medication/procedure history for botulinum toxin injections during pre‑implant evaluation and document timing in the record.

Billing unit limits — inv-16

Primary per‑DOS unit limit (selected codes)Codes 61850, 61860, 61863, 61867, 61870, 61880, 61885, 61886, 61888, 95961, 95970, 95976, 95977 = 1 unit per date of service

Two‑unit per‑DOS codesCodes 61864 and 61868 may bill 2 units per date of service.

Additional units when billed with primary procedureCode 95962 may be billed for up to an additional 7 units per date of service when billed with the primary procedure.

Coding referenceProviders must report the most specific CPT/HCPCS code that accurately describes the service; if no specific code exists use the appropriate unlisted procedure code (see CPT/HCPCS guidance).

Provider Requirements, Prior Authorization, and Billing Guidance

Prior Authorization

Prior Approval Required

Prior Approval Required — If the service requires prior approval, prior approval remains required for beneficiaries under 21 years of age; providers should follow NCTracks guidance and the EPSDT provider resources for any exceptions or additional instructions.

EPSDT does NOT waive prior approval when the policy requires it; verify requirements in NCTracks Provider Claims and Billing Assistance Guide.
Medicaid shall not require prior approval for deep brain stimulation specifically, but diagnosis editing applies — see Attachment A, letter B.

Billing Rule

Place-of-service Billing Guidance

Place-of-service billing guidance — Providers must bill services in the appropriate place of service. Certain neurophysiology CPT codes used with deep brain stimulation may be billed in the office or IDTF per guidance below.

Inpatient, Outpatient, and Independent Diagnostic Testing Facilities (IDTF) are acceptable places of service.
CPT codes 95970, 95976 and 95977 may be billed in the office setting.
CPT codes 95976 and 95977 may be billed in IDTF centers.
Follow NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, and UB-04 Data Specifications for correct billing.

Denial Risk

Claims May Be Denied if Beneficiary Eligibility Is Not Verified

Claims may be denied if beneficiary eligibility is not verified or if coverage/medical necessity criteria are not met.

Verify Medicaid beneficiary eligibility at each service encounter; services may be restricted by eligibility category.
Claims may be denied if the beneficiary does not meet Section 2.0 eligibility requirements or does not meet the criteria in Section 3.0.
Claims may be denied for duplicate services or services that are experimental, investigational, or part of a clinical trial.

Denial Risk

Specific Contraindications

Specific contraindications — Deep brain stimulation is contraindicated and therefore not covered when specific medical, surgical, neurologic, or other conditions would make surgery or stimulation unsafe or ineffective.

Medical, surgical, neurologic, or orthopedic co-morbidities that contraindicate DBS surgery or stimulation.
Conditions requiring repeated MRI where MRI cannot be safely performed under specialized protocols.
Cognitive impairment, dementia, or depression that would be worsened by or interfere with benefit from DBS.
Recent botulinum toxin injections within the last 4 months.
Planned use of diathermy in the future.

Documentation Required

Claims and Coding Documentation Requirements

Claims and coding documentation requirements — Providers must report diagnosis and procedure codes to the highest level of specificity and comply with CPT/HCPCS and ICD-10 coding instructions; unlisted procedures require special report guidance.

Report ICD-10-CM and PCS codes to the highest level of specificity that supports medical necessity using the current ICD-10 edition.
Report the most specific CPT/HCPCS billing code that accurately describes the procedure; use unlisted procedure codes with special report when no specific code exists.
Failure to report codes to the highest level of specificity that support medical necessity may trigger claim denial.
Follow NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, and UB-04 Data Specifications Manual.

Documentation Required

Documentation of Prior Therapies and Evaluation

Documentation must show that pharmacological, surgical, physical, or psychological therapies have been tried and proven unsatisfactory or are unsuitable/contraindicated prior to DBS implantation.

Document careful screening, evaluation, and confirmed diagnosis prior to implantation.
Document trials of other treatment modalities (pharmacologic, surgical, physical, psychological) and why they were unsatisfactory or contraindicated.
Document availability of facilities, equipment, and professional/support personnel for appropriate treatment, training, and follow-up.

Step Therapy

Step therapy — No step therapy requirements are specified for deep brain stimulation in this policy.

Although the policy requires trials of other modalities to be documented, no formal step therapy program or sequential-prefailure prior authorization process is defined.

Background and Rationale

Deep brain stimulation (DBS) delivers electrical stimulation through implanted electrodes targeted to specific brain regions to reduce symptoms of movement disorders. Programming is performed noninvasively and can be adjusted over time to balance symptom control and stimulation-related side effects such as dysarthria, disequilibrium, or involuntary movements. DBS requires appropriate pre‑implant evaluation, device implantation by qualified personnel, and ongoing programming and follow‑up.

Definitions and Reporting Notes

Definitions specific to this policy — inv-31

Definitions specific to this policyNone Apply.

ImplicationNo additional policy‑specific definitions are provided; use standard coding and clinical terminology.

ReferenceSee policy Definitions section for confirmation that no unique terms apply.

ICD-10-CM/PCS reporting — inv-32

ICD‑10‑CM/PCS specificityReport ICD‑10‑CM and PCS codes to the highest level of specificity that supports medical necessity.

Edition to useUse the current ICD‑10 edition and any subsequent editions in effect at the time of service.

Provider obligationRefer to the applicable ICD‑10 edition for code descriptions; codes are not listed verbatim in the policy text for description.

CPT/HCPCS unlisted procedure — inv-33

When no specific CPT/HCPCS existsReport the service using the appropriate unlisted CPT or HCPCS code and follow the Instructions for Use and Special Report requirements in the current codebook.

Follow current editionsUse the Current Procedural Terminology (CPT), HCPCS, and UB‑04 Data Specifications Manual editions in effect at time of service for coding and descriptions.

Documentation requirementProvide the required special report and supporting documentation when submitting unlisted procedure or service codes.