Prior authorization required; use InterQual criteria and listed codes

Coverage of deep brain and responsive cortical stimulation is subject to medical necessity review and prior authorization; submit requests referencing the InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes and include the applicable procedure and device codes when requesting review.

• Use listed CPT/HCPCS and HCPCS L‑codes (see coding section) on the prior authorization request.
• Reference InterQual clinical coverage criteria for implantation and procedure medical necessity determination.

Verify multidisciplinary selection and center expertise during prior auth

Prior authorization must verify that patient selection and the planned procedural setting meet multidisciplinary team and center expertise expectations described by guidelines (psychiatry, neuropsychiatry, clinical psychology, neurology, neurosurgery and DBS experience) before approval.

• Include documentation that patient selection was made by a multidisciplinary team experienced in managing the relevant disorder and DBS.
• Document that the procedure will be performed at a center with DBS expertise and experience managing the specific condition.

DBS for OCD is considered last‑line per guideline literature

Document that DBS is being considered only after standard treatments have failed; literature and guideline reviews generally recommend DBS as a last‑line therapy for OCD.

• Include prior treatment history showing failure of other evidence‑based therapies before DBS is pursued.

Document stepwise prior therapies and consideration of alternative surgeries

Prior authorization and medical record review require documentation of prior standard therapies and consideration of alternative surgical options; include rationale for choosing DBS over ablative surgery and evidence of medically refractory disease.

• Provide records of prior pharmacologic, psychotherapeutic, and neuromodulatory treatments and their outcomes.
• Document discussions of surgical alternatives (e.g., lesioning) including risks, patient preference, and clinician experience.

Provide medical records and use listed procedure/device codes

Medical records and the procedure/diagnosis codes listed in the coding section may be required to assess whether the member meets clinical criteria; include operative notes, diagnostic assessments, and relevant CPT/HCPCS/L‑codes on submissions.

• Attach operative reports, pre‑ and post‑operative assessments, and specialist consultation notes.
• List applicable procedure and device codes on authorization and claims; inclusion of a code does not guarantee coverage or payment.

Document multidisciplinary evaluation and center expertise

Documentation should reflect multidisciplinary evaluation and center experience — include notes from psychiatry, neuropsychiatry or clinical psychology, neurology, and neurosurgery documenting consensus on candidacy and management plan.

• Include signed consultation notes from each relevant specialty documenting assessment, rationale, and treatment recommendations.
• Document center-level DBS experience and team composition.

Documentation may affect but does not guarantee coverage

Medical records submitted to support a request may be necessary to determine whether coverage criteria are met, but providing documentation does not guarantee approval; coverage remains subject to the member’s specific benefit plan and applicable laws.

• Ensure documentation aligns with InterQual criteria and member specific benefit plan terms.
• Recognize that documentation aids review but does not itself establish coverage.

NICE research‑only recommendation for DBS in OCD may affect coverage

NICE guidance states DBS for chronic, severe, treatment‑resistant OCD should only be used in the context of research due to inadequate evidence quality and quantity; absence of evidence that the proposed treatment meets research or center criteria may lead to denial.

• If DBS is proposed outside a research context, include justification that addresses NICE concerns or evidence of research framework/oversight if applicable.
• Document center-level participation in research or protocols when available.