CurrentBaylor Scott & White Health PlanPolicy 025

Deep Brain Stimulation (DBS) — Medical Coverage Policy

Policy governing prior authorization, coding, and medical necessity considerations for deep brain stimulation (DBS) services for Baylor Scott & White Health Plan members across applicable lines of business.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyDeep Brain Stimulation (DBS) — Medical Coverage Policy

Policy CodePolicy 025

Change TypeNo material change

Effective DateMar 1, 2026

Next Review DateFeb 26, 2027

Key ActionObtain prior authorization and submit multidisciplinary evaluation documentation demonstrating symptoms inadequately controlled with optimized medical therapy, device details, and target brain structure.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Prior Authauthorization requirement

Multiple codescodes provided

Medicare/Medicaid/Commerciallines of business

025internal id

Coverage & Medical Necessity Criteria

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Medical Necessity Criteria

Covered when ALL of the following are met

DBS candidate criteria: Patient has a movement disorder (e.g., Parkinson's disease, Essential Tremor, dystonia) or a select neuropsychiatric condition (e.g., refractory obsessive‑compulsive disorder) AND symptoms are inadequately controlled with optimized medical therapy AND functional impairments significantly impact activities of daily living AND a comprehensive multidisciplinary evaluation including neurology and neurosurgery supports DBS and identifies an appropriate brain target

Use device‑specific FDA indications and applicable Medicare NCD/LCD or state TMPPM criteria when they exist.

Coding — CPT, HCPCS, ICD-10, and Billing Rules

Covered CPT CodesCPTCovered

61863	Twist drill, burr hole, craniotomy or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site; first array
+61864	Each additional array (list separately in addition to primary procedure)
61867	Stereotactic implantation with use of intraoperative microelectrode recording, each additional array
+61868	Each additional array for stereotactic implantation with intraoperative microelectrode recording
61880	Revision or removal of intracranial neurostimulator electrodes
61885	Insertion or replacement of cranial neurostimulator pulse generator or receiver; with connection to a single electrode array
61886	Insertion or replacement of cranial neurostimulator pulse generator or receiver; with connection to 2 or more electrode arrays
95836	Electrocorticogram from an implanted brain neurostimulator pulse generator/transmitter, including recording, with interpretation and written report, up to 30 days
95961	Functional cortical and subcortical mapping by stimulation and/or recording of electrodes; initial hour
+95962	Each additional hour of attendance for functional mapping

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Covered HCPCS / Device CodesHCPCSCovered

L8680	Implantable neurostimulator electrode, each
L8681	Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only
L8682	Implantable neurostimulator radiofrequency receiver
L8683	Radiofrequency transmitter (external) for use with implantable neurostimulator
L8685	Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
L8686	Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension
L8687	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
L8688	Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension
L8689	External recharging system for battery (internal) for use with implantable neurostimulator, replacement only
C1767	Generator, neurostimulator (implantable), non-rechargeable

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Applicable ICD-10 Diagnosis Codes (examples)ICD-10

G20	Parkinson's disease
G25.0	Essential tremor
G24.1	Genetic torsion dystonia
G24.2	Idiopathic nonfamilial dystonia
G24.3	Spasmodic torticollis
G24.8	Other dystonia
G24.9	Dystonia, unspecified
G25.2	Other specified forms of tremor
M43.6	Torticollis

Bilateral stimulation coding rule — modifier guidance and billing notes

Rule summaryFor bilateral stimulation via implantation of two cranial neurostimulator pulse generators, each connected to a single lead, add modifier -50 to either 61885 or 61886.

Single-generator bilateral configurationFor bilateral stimulation via implantation of one cranial neurostimulator pulse generator connected to two leads, report 61886 (do not append -50).

Device billing noteDevice HCPCS codes (e.g., L8680, L8681, L8686, L8688) are billed by the supplying entity (typically the facility) and are not subject to the member's DME benefit limit when surgically implanted.

Provider Actions, Authorization & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization is required for Deep Brain Stimulation (DBS) procedures and all associated services, including device implantation, programming, revisions, and related inpatient or outpatient care. Requests submitted without prior authorization will be denied. Refer to the member's Evidence of Coverage (EOC) or Summary Plan Description (SPD) for plan-specific prior authorization procedures and any additional benefit requirements.

Includes implantation, programmer visits, device revisions, and related services
Requests lacking prior authorization will be denied

Documentation Required

Clinical Evaluation & Device Information

Clinical Evaluation and Device Information: Documentation must include a comprehensive multidisciplinary evaluation supporting medical necessity. Submit clinical records from neurology and neurosurgery (or equivalent specialists) that describe the patient's diagnosis, symptom severity, prior treatment history, and functional impairment. Include objective pre-procedure assessments, evidence that symptoms were inadequately controlled with optimized medical therapy, and the rationale for the selected brain target (e.g., STN, GPi, VIM). Provide detailed device information: manufacturer, model, FDA indication (if applicable), laterality (unilateral vs bilateral), proposed lead and pulse generator specifics, and planned programming/therapy parameters.

Multidisciplinary evaluation required (neurology + neurosurgery)
Document prior optimized medical therapy and objective assessments
Provide device manufacturer, model, indication, laterality, and planned parameters

Background

Deep Brain Stimulation (DBS) is a neurosurgical therapy that delivers controlled electrical stimulation to targeted brain regions through implanted electrodes connected to an implanted pulse generator. Modern DBS systems are used primarily to treat movement disorders — including Parkinson's disease, Essential Tremor, and dystonia — and select neuropsychiatric conditions such as refractory obsessive–compulsive disorder. Common brain targets include the subthalamic nucleus (STN), internal globus pallidus (GPi), and ventral intermediate (VIM) nucleus of the thalamus. Stimulation may be unilateral or bilateral depending on symptom distribution and clinical need.

Definitions & System Capabilities

Deep Brain Stimulation (DBS) — definition and clinical context

DefinitionA neurosurgical therapy that delivers controlled electrical stimulation to targeted regions of the brain through implanted electrodes connected to an implanted pulse generator.

Indications (examples)Used for movement disorders (Parkinson's disease, essential tremor, dystonia) and select neuropsychiatric conditions (e.g., refractory OCD); device-specific FDA indications vary by manufacturer and model.

Patient selectionTypically reserved for patients whose symptoms are inadequately controlled with optimized medical therapy and whose functional impairments significantly impact activities of daily living; decision requires multidisciplinary evaluation (neurology and neurosurgery).

Modern DBS system capabilities

Core capabilitiesMay include directional leads, sensing-enabled stimulation, and rechargeable or non-rechargeable implantable pulse generators, enabling more precise targeting and individualized therapy optimization.

Advanced featuresSome systems support remote programming capabilities and device-specific programming options; indications and programming capabilities vary by manufacturer and model.

Clinical impactModern features (directional leads, sensing) facilitate improved symptom control and tailored therapy adjustments during follow-up programming sessions.