Magnetic Resonance–Guided Focused Ultrasound (MRgFUS) for Essential Tremor
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Medical necessity and coverage criteria for magnetic resonance-guided focused ultrasound (MRgFUS) as a treatment for medication‑refractory essential tremor, applicable to eocco members and providers submitting prior authorization.
No material clinical or coverage changes in this revision.
Coverage Criteria for MRgFUS
inv-01: Medical Necessity (Covered when ALL are met)
Covered when ALL of the following are met:
Eligibility alternatives
- Not eligible or failed DBS: Member is not eligible for deep brain stimulation (DBS) or has failed DBS but has no retained cranial implants
- Multidisciplinary evaluation: Member has been evaluated by a multidisciplinary team and MRgFUS is considered the best course of treatment
inv-02: Investigational / Not Covered Indications
MRgFUS is considered investigational for the following indications:
These indications are categorized as investigational (not established as covered).
The policy identifies a specific list of investigational indications for MRgFUS that are outside the scope of covered treatment. These investigational uses include treatment of medication‑refractory tremor‑dominant Parkinson's disease, treatment of uterine fibroids, and treatment of other tumors (for example, prostate cancer, brain cancer, and desmoid tumors).
Any indication explicitly listed as investigational in this policy is considered not medically necessary and therefore not eligible for coverage under this policy.
Coding and Diagnosis
| 61715 | Magnetic resonance image-guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed |
| No codes listed |
| G25.0 | Essential Tremor |
Provider Actions and Authorization Requirements
Prior authorization required; include chart notes
Prior authorization is required for requests involving CPT 61715; submit a prior authorization request that includes chart notes documenting how the member meets all medical necessity criteria for MRgFUS.
- Include documentation showing the member meets each coverage criterion (medication-refractory status, tremor severity affecting ADLs, and applicable eligibility alternative).
- Include the applicable procedure code (61715) on the request.
Require ≥2 failed medication trials including a first-line agent
Member must have failed at least two trials of medical therapy, including at least one first-line agent (for example, propranolol or primidone), before MRgFUS is considered medically necessary.
- Document two or more pharmacologic therapy trials, with at least one being a first-line agent.
Submit chart notes with prior authorization
Chart notes must be submitted with the prior authorization request to demonstrate the member meets all coverage criteria.
- Submit clinical notes that document: number and type of medication trials, tremor description and impact on ADLs, and evaluation by multidisciplinary team or DBS eligibility as applicable.
Requests missing criteria will be denied/not approved
Requests that do not meet ALL medical necessity criteria will be denied or not approved (examples include fewer than two medication trials, tremor not affecting ADLs, or treatment for tremor-dominant Parkinson's disease).
- Verify medication-refractory definition (≥2 trials including ≥1 first-line agent) is met.
- Verify tremor is moderate to severe in dominant hand and affects activities of daily living.
- Do not submit MRgFUS for investigational indications (e.g., tremor-dominant Parkinson's disease, uterine fibroids, other tumor treatments).
Definitions and Background
Magnetic resonance‑guided focused ultrasound (MRgFUS) is a noninvasive, MRI‑guided procedure that produces a thermal lesion in targeted thalamic tissue (ventral intermediate nucleus) to create a unilateral thalamotomy and reduce contralateral upper‑extremity tremor. This policy applies to FDA‑approved unilateral MRgFUS for medication‑refractory essential tremor when specified eligibility criteria are met, including documentation of failed medical therapy and functional impact on activities of daily living.
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