ModifiedCapital BluecrossPolicy MP 1.042

Deep Brain Stimulation

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Medical policy governing coverage and medical necessity criteria for deep brain stimulation (DBS) procedures for movement disorders and select neurologic/psychiatric indications for members of Capital BlueCross programs.

Policy Summary

PayerCapital Bluecross

PolicyDeep Brain Stimulation

Policy CodePolicy MP 1.042

Change TypeMaterial updates to coverage stance and coding

Effective DateJun 1, 2026

Last ReviewFeb 11, 2025

Next Review DateFeb 11, 2026

Key ActionObtain prior authorization and document levodopa response and required medication trials before submitting for DBS.

SourceLink

POLICY UPDATE CHANGES

Epilepsy was moved from Medically Necessary to Investigational in the policy.

Investigational criteria for adaptive brain stimulation were added.

Two analysis procedure codes were removed because they are not applicable to the brain.

Benefit Variations section and disclaimer were updated/removed in an administrative update.

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ModifiedCapital BluecrossPolicy MP 1.042

Deep Brain Stimulation

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Policy Summary

PayerCapital Bluecross

PolicyDeep Brain Stimulation

Policy CodePolicy MP 1.042

Change TypeMaterial updates to coverage stance and coding

Effective DateJun 1, 2026

Last ReviewFeb 11, 2025

Next Review DateFeb 11, 2026

Key ActionObtain prior authorization and document levodopa response and required medication trials before submitting for DBS.

SourceLink

POLICY UPDATE CHANGES

Epilepsy was moved from Medically Necessary to Investigational in the policy.

Investigational criteria for adaptive brain stimulation were added.

Two analysis procedure codes were removed because they are not applicable to the brain.

Benefit Variations section and disclaimer were updated/removed in an administrative update.

6+FDA‑cleared DBS systems listed

>=7min age for primary dystonia

3 monthsmedication trial prior to DBS

4 yearsPD duration threshold

multipleconditions reviewed

extensivereferences

Coverage Criteria and Policy Stance

Medically necessary indications

Investigational / Not covered due to insufficient evidence

Adaptive deep brain stimulation for Parkinson disease: Adaptive (closed‑loop) deep brain stimulation (aDBS) of the globus pallidus interna or subthalamic nucleus is considered investigational for Parkinson disease.

One RCT and limited feasibility data exist; evidence is insufficient to determine improvement in net health outcome.

ref":"b0_1","title":"Investigational / Insufficient evidence indications"},{

citations":["18","19","17","16"],"intro":"Summary of evidence-based coverage stance for various indications:","nodes":["{\"operator\":\"any\",\"label\":\"Psychiatric indications (major depressive disorder, OCD)\",\"text\":\"Randomized trials and meta-analyses have produced mixed or negative results (several RCTs terminated for futility or not showing significant benefit); adverse psychiatric events have been reported. Evidence is insufficient to determine improvement in net health outcome.\",\"threshold\":\"evidence insufficient\",\"children\":[]}","{\"operator\":\"any\",\"label\":\"Other neurologic/psychiatric disorders (MS, chronic pain, alcohol use disorder, anorexia nervosa, Alzheimer disease, Huntington disease)\",\"text\":\"Available data include small RCTs and case series; number and size of trials are inadequate to draw conclusions regarding efficacy and net health outcome; additional RCTs needed.\",\"threshold\":\"evidence insufficient\",\"children\":[]}","{\"operator\":\"any\",\"label\":\"Movement disorders (Parkinson disease, dystonia, essential tremor, tardive dyskinesia)\",\"text\":\"For Parkinson disease, dystonia, and essential tremor, multiple RCTs, systematic reviews, and long‑term follow-up studies support evaluation of DBS with condition‑ and target‑specific evidence (STN, GPi, thalamus). Evidence is substantial for primary dystonia and for appropriately selected PD and tremor patients meeting criteria.\",\"threshold\":\"condition-specific evidence varies\",\"children\":[]}","{\"operator\":\"any\",\"label\":\"Epilepsy and Tourette syndrome\",\"text\":\"Clinical trials and registry data exist for anterior nucleus thalamic stimulation in refractory epilepsy and for DBS in Tourette syndrome; RCTs and registries report mixed results with ongoing evaluation of efficacy and target selection.\",\"threshold\":\"condition-specific evidence varies\",\"children\":[]}"],"ref":"b0_2","title":"Coverage summary by indication"},{

citations":["43","44"],"intro":"Policy-level coverage stance changes recorded in history entries","nodes":["{\"operator\":\"any\",\"n\":1,\"label\":\"Epilepsy coverage status change\",\"text\":\"Epilepsy was moved from Medically Necessary (MN) to Investigational (INV).\",\"note\":\"Documented in multiple policy history entries (policy history and administrative notes).\",\"children\":[]}"]

ref':'b0_3

title":"Coverage stance updates"}]}{

Deep brain stimulation is contraindicated in individuals who are poor surgical candidates. Specific contraindications that would support denial include: patients with unstable medical problems or cardiac pacemakers; patients who require repeated magnetic resonance imaging (MRI); patients with dementia that may interfere with cooperation; and patients who have received botulinum toxin injections within the last 6 months.

This policy distinguishes between explicit exclusions and indications described as having insufficient evidence. Several neurologic and psychiatric uses (for example, treatment‑resistant major depressive disorder, obsessive‑compulsive disorder, chronic pain, multiple sclerosis, alcohol use disorder, and other listed conditions) are characterized here as investigational/insufficient evidence rather than being formally excluded; the evidence from randomized trials and case series is generally limited, mixed, or underpowered and does not demonstrate consistent net health outcome benefit.

An administrative coding update removed two analysis procedure codes because they are not applicable to the brain. Providers should confirm they are using current, applicable procedure and diagnosis codes when submitting claims to avoid potential billing errors or claim denials.

Adaptive deep brain stimulation (aDBS), a closed‑loop system that uses brain signal feedback to adjust stimulation parameters, is considered investigational in this policy. One randomized trial and ongoing studies are noted, but the available evidence is insufficient to conclude that aDBS improves net health outcomes for Parkinson disease; the policy history documents addition of investigational criteria for aDBS during the 07/01/2025 major review.

For psychiatric indications such as treatment‑resistant major depressive disorder and obsessive‑compulsive disorder, randomized trials and meta‑analyses have produced mixed or negative results, including trials terminated for futility and some reporting increased adverse psychiatric events. The policy therefore characterizes these psychiatric indications as having insufficient evidence to establish net clinical benefit, and DBS for these disorders is listed as investigational.

Deep brain stimulation for epilepsy is listed as Investigational (INV) in the current policy. Although randomized trials of anterior nucleus thalamic stimulation and observational studies have reported some reductions in seizure frequency, results were inconsistent across trial phases, adverse events were substantial, and long‑term data are limited; the policy history documents the move of epilepsy from Medically Necessary to Investigational.

Coding and Billing References

FDA device product codes and PMA identifiers mentionedmixed

P960009	Activa® Deep Brain Stimulation Therapy System (PMA product code listed)
MBX	FDA product code for Activa (listed)
NHL	FDA product code used for several DBS systems (listed)
MHY	FDA product code listed for Percept PC and other systems

Covered when medically necessary (procedures referenced)CPT

95983	Deep brain stimulation intraoperative neurophysiology monitoring (as listed)
61863	Stereotactic implantation of neurostimulator electrode(s); foramen ovale (as listed)
95984	Intraoperative neurophysiology monitoring (other code pairing shown)
61868	Stereotactic implantation of neurostimulator electrode(s), cerebral
61880	Stereotactic implantation of neurostimulator electrode array and pulse generator, etc.
61885	Removal or replacement of neurostimulator lead
61886	Revision of neurostimulator lead
61888	Implantation or replacement of neurostimulator pulse generator
95970	Unlisted neurophysiology code referenced in pairings

Covered when medically necessary (device/supply HCPCS/L codes referenced)HCPCS

L8686	Implantable neurostimulator device, DBS lead (supply code context)
C1778	Implantable neurostimulator device HCPCS (paired in list)
L8687	Related device supply code
C1820	Lead component HCPCS
L8688	Related device supply code
C1883	Device component HCPCS
L8689	Related device supply code
L8679	Battery/pulse generator supply code
L8695	Related device supply code
L8680	Related supply code

1–10 of 14

1/2

Covered when medically necessary: diagnosis codes referencedICD-10Covered

G20.A1	Parkinson's disease without dyskinesia, without mention of fluctuations
G20.A2	Parkinson's disease without dyskinesia, with fluctuations
G20.B1	Parkinson's disease with dyskinesia, without mention of fluctuations
G20.B2	Parkinson's disease with dyskinesia, with fluctuations
G20.C	Parkinsonism, unspecified
G21.0	Malignant neuroleptic syndrome
G21.11	Neuroleptic induced parkinsonism
G21.19	Other drug induced secondary parkinsonism
G21.2	Secondary parkinsonism due to other external agents
G21.3	Postencephalitic parkinsonism

1–10 of 24

1/3

Coding changesmixed

removed codes (two analysis procedure codes)

Two analysis procedure codes removed from policy as not applicable to the brain (specific codes not listed in these chunks).

Diagnosis codes mentionedICD-10

G40 ICD-10 codes

Associated epilepsy G40 ICD-10 codes were added to the policy when epilepsy was previously moved from investigational to medically necessary (historical entry).

inv-17: UPDRS motor score (off medication) — numeric threshold expectation

ThresholdMinimum score of 30 points on the motor portion of the Unified Parkinson Disease Rating Scale (UPDRS) when the patient has been off medication for approximately 12 hours

Alternate disease-duration optionParkinson disease duration of at least 4 years may be used instead of the UPDRS threshold

Context for useThis threshold applies when levodopa responsiveness and motor complications not controlled by pharmacologic therapy are documented

inv-18: Definition of drug-resistant epilepsy — reference to ILAE consensus definition

Source reference

Provider Requirements, Authorization, and Billing Guidance

Prior Authorization

Obtain prior authorization and document that policy criteria are met

Prior authorization is required for deep brain stimulation. The request must document that the patient meets the policy criteria (for example: levodopa responsiveness for Parkinson disease; motor complications not controlled by pharmacologic therapy; and either a UPDRS motor score ≥30 off medication after ~12 hours or Parkinson disease duration ≥4 years; or medication trial duration and disabling tremor criteria for tremor indications).

Document levodopa response and motor complications not controlled by pharmacologic therapy for PD.
If using the UPDRS option, document motor portion score ≥30 after ~12 hours off medication, or document PD duration ≥4 years.
For tremor indications, document disabling, medically unresponsive tremor and inadequate control by maximal medication for ≥3 months.

Note

Coverage depends on member benefits and coding table

Coverage determination is governed by the member's benefit program and eligibility; the coding section lists procedure and supply codes, but identification of a code does not imply coverage.

Background and Scope

Deep brain stimulation (DBS) is a neurosurgical procedure involving stereotactic implantation of electrodes into targeted brain structures (commonly the thalamus, globus pallidus interna [GPi], or subthalamic nucleus [STN]) connected to an implanted neurostimulator. Temporary intraoperative stimulation may be used to assess response prior to permanent implantation, and post‑implant programming of stimulation parameters is performed noninvasively to balance symptom control against stimulation‑related adverse effects.

Definitions and Clinical Terms

inv-32: Disabling, medically unresponsive tremor — definition and time/medication threshold

Core definitionTremor causing significant limitation in daily activities and inadequately controlled by maximal dosage of medication for at least 3 months prior to implant

Documentation expectationClinical documentation should demonstrate disabling, medically unresponsive tremor with specific examples of limitations in daily activities

Medication thresholdInadequate control despite maximal tolerated pharmacologic therapy for a minimum of 3 months before consideration of DBS

inv-33: Adaptive deep brain stimulation (aDBS) — definition and investigational status

DefinitionAdaptive deep brain stimulation (aDBS) is a closed-loop DBS system that incorporates feedback from brain signals to dynamically adjust stimulation parameters.

Policy stance

Policy Revision History

2025-07-01major_review

Major review added investigational (INV) criteria for adaptive (closed-loop) deep brain stimulation.

2025-10-09administrative_update

Removed Benefit Variations section and updated disclaimer.

2026-02-11consensus_reviewLatest

Policy Summary

PayerCapital Bluecross

PolicyDeep Brain Stimulation

Policy CodePolicy MP 1.042

Change TypeMaterial updates to coverage stance and coding

Effective DateJun 1, 2026

Last ReviewFeb 11, 2025

Next Review DateFeb 11, 2026

Key ActionObtain prior authorization and document levodopa response and required medication trials before submitting for DBS.

SourceLink

On This Page

ILAE consensus definition: Kwan P, Arzimanoglou A, Berg AT, et al. Definition of drug resistant epilepsy: consensus proposal (Epilepsia. 2010).

MeaningPolicy references the ILAE consensus definition for 'drug-resistant epilepsy' to define refractory epilepsy considered in DBS contexts

Action for providersSee Kwan et al. 2010 for criteria used to determine drug resistance prior to considering neuromodulation options

Verify member benefit program terms and any benefit limitations before proceeding.
Use the coding section only as a reference—final coverage depends on benefit contract and medical necessity determinations.

Prior Authorization

Obtain prior authorization using current codes

Providers should obtain prior authorization using current procedure and diagnosis codes; the policy has been reviewed and coding updated—prior authorization requirements apply as outlined in the main policy.

Submit authorization requests with up-to-date CPT/HCPCS/ICD-10 codes listed in the policy.
Coding reviews noted in the policy history; check for recent code changes before submission.

Step Therapy

Document medication trials (including levodopa where applicable)

Providers must document trials of maximal tolerated pharmacologic therapy prior to DBS authorization, including levodopa trial for Parkinson disease and appropriate medication trials for tremor.

For tremor: document inadequate control by maximal medication doses for at least 3 months.
For Parkinson disease: document levodopa responsiveness and ongoing motor complications despite pharmacologic therapy.

Note

Follow clinical guidelines and benefit program rules

Providers remain responsible for following applicable clinical guidelines and the member's benefit program rules; medical policies do not guarantee coverage or payment.

Confirm that the requested DBS intervention is medically necessary under the member's benefit program.
Follow clinical guideline recommendations and policy criteria when preparing authorization documentation.

Step Therapy

No step therapy requirements specified

No step therapy requirements are specified in the policy excerpts provided.

There are no policy-directed sequential medication or treatment step requirements stated in these chunks.

Documentation Required

Provide clinical documentation of disabling tremor and medication trials

Clinical documentation submitted for authorization should demonstrate disabling, medically unresponsive tremor (significant limitation in daily activities) and the documented medication trials or levodopa response as applicable.

Record limitations in activities of daily living caused by tremor.
Include medication dosing history showing maximal tolerated therapy and duration (≥3 months for tremor).
For PD, include levodopa response documentation and motor complication details.

Billing Rule

Verify member eligibility and benefit limitations

Providers must verify member eligibility and benefit limitations prior to providing services; medical policies are not guarantees of coverage or payment.

Check eligibility and the member's benefit contract on the date of service.
Understand that final claim payment is subject to benefit terms, exclusions, and medical necessity determinations.

Billing Rule

Use current applicable procedure and diagnosis codes

Use current, applicable procedure and diagnosis codes when requesting authorization and submitting claims; the policy notes that two non-brain analysis procedure codes were removed after coding review.

Reference the policy's coding section for the applicable CPT, HCPCS, and ICD-10 codes, and confirm no recently removed or obsolete codes are used.
Update billing systems if codes noted as removed or revised in policy history apply to submitted services.

Denial Risk

Contraindications that may trigger denial

DBS is contraindicated in patients who are poor surgical risks (unstable medical problems), those requiring repeated MRI, those with dementia interfering with cooperation, or those with cardiac pacemakers; these contraindications may lead to denial.

Patients with unstable medical problems or cardiac pacemakers are not good surgical candidates for DBS.
A history of recent botulinum toxin injections (within 6 months) or need for repeated MRI are contraindications.
Dementia that impairs cooperation is a contraindication and may result in denial.

Note

Code listing does not guarantee coverage; check member benefits

Identification of a code in the policy does not denote coverage; final coverage and payment are determined by the member's benefit information and medical necessity review.

Do not assume listing of a procedure or supply code guarantees coverage—verify under the member's benefit plan.
Final payment is subject to contract terms, benefit limitations, and medical necessity.

Billing Rule

Risk of claim denial if obsolete/removed codes are used

Removal of inapplicable analysis procedure codes was recorded in the policy history; using obsolete or removed codes on claims may trigger denial.

Confirm that analysis procedure codes removed from the policy are not used on authorization requests or claims.
Billing with obsolete codes increases the risk of claim denial—use current codes listed in the policy.

aDBS for Parkinson disease is considered investigational due to insufficient evidence to support a general conclusion about health outcomes

Regulatory/context noteFDA submission for aDBS was as an optional programming feature and labeling notes limits (e.g., not studied with more than one implanted neurostimulator)

inv-34: Dysarthria — definition

DefinitionDysarthria: difficult, poorly articulated speech resulting from interference in the control and execution of the muscles of speech, usually caused by damage to a central or peripheral motor neuron.

Clinical relevanceRecognized as a potential stimulation-related adverse effect to balance when programming neurostimulators

AssessmentDocument speech impairment characteristics to differentiate dysarthria from other speech disorders

inv-35: Globus pallidus — anatomical definition

Anatomical definitionGlobus pallidus: the smaller and more medial part of the lentiform nucleus, separated from the putamen by the lateral medullary lamina and divided into external and internal portions, closely connected to the thalamus and mesencephalon.

Clinical targetsThe globus pallidus interna (GPi) is a recognized DBS target for Parkinson disease and primary dystonia

Relation to other structuresAnatomically adjacent to the putamen and functionally connected with thalamic circuits involved in motor control

inv-36: Thalamus — anatomical definition

Anatomical definitionThalamus: one of a pair of large oval gray-matter structures forming most of the lateral walls of the third ventricle that relays sensory and motor information (excluding smell) to the cerebral cortex.

Clinical relevanceThalamic stimulation (VIM region) is an established DBS target for essential tremor and tremor-predominant Parkinson disease

Laterality noteThalamic electrodes are often implanted unilaterally corresponding to the side with most severe symptoms; bilateral use is considered for bilateral disabling tremor

inv-37: UPDRS — definition of the scale

DefinitionUnified Parkinson Disease Rating Scale (UPDRS): a rating tool used to follow the longitudinal course of Parkinson's disease, including a motor subsection used to assess severity off medication.

Use in policyThe motor portion score (off medication ~12 hours) is used as a numeric threshold (minimum 30 points) for DBS candidacy in Parkinson disease when levodopa response and uncontrolled motor complications are documented

Clinical applicationUPDRS motor scores and disease duration criteria are alternative thresholds referenced in coverage criteria for STN/GPi DBS

inv-38: CMS NCD for DBS — reference to Medicare national coverage determination

NCD identificationCenters for Medicare & Medicaid Services (CMS) National Coverage Determination (NCD) for Deep Brain Stimulation for Essential Tremor and Parkinson's Disease (NCD 160.24).

AccessReferenced CMS NCD URL and document details cited in policy references (accessed February 25, 2025)

Policy relevanceThe CMS NCD is cited as a regulatory reference supporting coverage considerations for ET and PD DBS within the policy

Consensus review updated policy guidelines and references; epilepsy listed as Investigational (INV) and coding was reviewed with removal of two analysis procedure codes not applicable to the brain.

2023-05-22minor_review

Moved epilepsy from Investigational (INV) to Medically Necessary (MN) with additional criteria and added associated G40 ICD-10 codes.