CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Adrenal-to-Brain (Adrenal Medullary) Transplantation for Parkinson's Disease

This policy governs coverage and medical necessity determinations for adrenal medullary tissue transplantation into the brain (autograft or fetal allograft) for treatment of Parkinson's disease for Blue Cross Blue Shield - Rhode Island members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAdrenal-to-Brain (Adrenal Medullary) Transplantation for Parkinson's Disease

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateFeb 6, 2010

Next Review Date

Key ActionDo not submit claims for adrenal-to-brain transplantation (HCPCS S2103) as it is not covered / considered not medically necessary.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredCoverage stance

S2103Not covered code

2003AHRQ review

1999AAN guidance

Coverage Determinations

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General coverage determination

Covered when ALL of the following are met:

Overall coverage stance: Adrenal-to-brain transplantation with autograft or fetal allograft is not covered for BlueCHiP for Medicare and considered not medically necessary for Commercial Products; no medical criteria apply.

Medical criteria: Not applicable (policy states 'Not applicable').

Provider Requirements and Billing Guidance

Prior Authorization

Not applicable.

Note

Benefit Verification

Refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine benefits and eligibility for this service.

Billing Rule

Member Billing

Providers may not bill members for services determined to be not medically necessary or non-covered benefits unless the member was informed and provided written agreement in advance to continue treatment at their own expense. For member-specific benefit questions, contact the provider call center.

Denial Risk

Denial / Not Medically Necessary

Claims for adrenal-to-brain transplantation (S2103) will be denied for BlueCHiP for Medicare and considered not medically necessary for Commercial products.

S2103 Adrenal tissue transplant to brain

Clinical Background

Adrenal medullary tissue transplantation involves implanting adrenal medullary tissue into the striatum (for example, the caudate nucleus or putamen) with the goal of restoring depleted striatal dopamine in Parkinson’s disease. Techniques reported in the literature include autotransplantation (simultaneous adrenalectomy and intracranial implantation of adrenal medullary fragments) and fetal allografting (harvested adrenal tissue from a fetus implanted into the recipient brain). Published data are limited, and professional and systematic-review bodies have concluded that evidence is insufficient to demonstrate benefit, leading to the policy determination of no coverage or not medically necessary status.

Procedural Definitions

Autotransplantation — definition and procedural details

DefinitionSimultaneous adrenalectomy and craniotomy with implantation of adrenal medullary tissue fragments into the caudate nucleus or putamen, sometimes anchored with staples or Gelfoam; can be performed via open microsurgical or stereotactic techniques.

Implantation sitesTypically implanted in fragments into the caudate nucleus at the margin of the lateral ventricle (exposed to CSF); the putamen has also been used.

TechniquesOpen microsurgical insertion or stereotactic localization and implantation using a cannula.

Anchoring methodsTissue fragments may be anchored in place with surgical staples or with Gelfoam.

Clinical rationaleIntended to restore depleted striatal dopamine to ameliorate motor and postural dysfunctions of Parkinson’s disease.

Allografting (fetal allograft) — definition and procedural details

DefinitionHarvesting adrenal tissue from an aborted fetus and implantation into the recipient brain using surgical techniques similar to autotransplantation (except no adrenalectomy of the recipient).

Procedural similaritySurgical implantation techniques mirror autotransplantation: tissue fragments implanted into caudate nucleus or putamen via open microsurgical or stereotactic approaches.

Intended effectAims to restore striatal dopamine activity to reduce motor and postural dysfunction in Parkinson’s disease.

Evidence summaryPublished data are scarce; systematic review (AHRQ 2003) found lack of efficacy and substantial morbidity; professional bodies (AAN 1999) cite safety concerns.