CurrentUnitedHealthcarePolicy SRST2026T0321MM

Deep Brain and Cortical Stimulation – Surest Medical Policyopen_in_new

Defines medical necessity coverage and not-medically-necessary positions for deep brain stimulation (DBS) and responsive cortical stimulation (RCS), lists applicable procedure and supply codes, references InterQual criteria for detailed clinical coverage, and summarizes evidence and FDA information. Applies to UnitedHealthcare policy SRST2026T0321MM effective April 1, 2026.

Policy Summary

PayerUnitedHealthcare

PolicyDeep Brain and Cortical Stimulation – Surest Medical Policyopen_in_new

Policy CodePolicy SRST2026T0321MM

Change TypeApplicable Codes revised; CPT removals

Effective DateApr 1, 2026

Next Review Date

Key ActionUnitedHealthcare refers to InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes for medical necessity clinical coverage criteria; providers must document criteria consistent with InterQual to support coverage.

SourceLink

POLICY UPDATE CHANGES

Applicable Codes updated and CPT codes 61850, 61860, 61863, 61864, and 64999 removed from the policy.

4Covered Indications listed as medically necessary

2Device types discussed (DBS, RCS)

5CPT codes listed as applicable

Coverage Summary

Policy SRST2026T0321MM (effective 04/01/2026, last reviewed 04/01/2026) addresses coverage determinations for deep brain stimulation (DBS) and responsive cortical stimulation (RCS/RNS). The policy status is CURRENT and the coverage stance is mixed, listing specific indications that are medically necessary (DBS for dystonia, essential tremor, Parkinson disease, and refractory focal/partial epilepsy; RCS for refractory partial or focal seizure disorder) and other indications that are not medically necessary/unproven (e.g., DBS/RCS for obsessive-compulsive disorder and all other indications).

The policy summarizes applicable procedure and device supply codes for reference and notes an administrative update on 04/01/2026 that revised applicable codes (removed CPT codes 61850, 61860, 61863, 61864, and 64999) and updated supporting information. FDA approvals and device listings are included for informational purposes only and FDA approval alone is not a basis for coverage. UnitedHealthcare may use InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes to determine detailed medical necessity clinical coverage criteria.

Key facts

Covered indications count4

Device types discussedDBS, RCS (Responsive Cortical Stimulation)

CPT codes listed count5

Policy numberSRST2026T0321MM

Effective dateApril 1, 2026

Last review dateApril 1, 2026

Medical Necessity and Coverage Criteria

Medically Necessary Indications

Deep brain stimulation is proven and medically necessary for treating the following indications:

ANY of the following

Dystonia
Essential tremor
Parkinson disease
Refractory epilepsy for a partial or focal seizure disorder

Responsive Cortical Stimulation Medically Necessary Indications

Responsive cortical stimulation is proven and medically necessary for treating:

ALL of the following

Refractory partial or focal seizure disorder

Not Medically Necessary / Unproven Indications

The following are unproven and not medically necessary due to insufficient evidence of efficacy:

ANY of the following

Deep brain stimulation and/or cortical stimulation for treating obsessive-compulsive disorder and all other indications
Responsive cortical stimulation for treating all other indications

Reference to External Detailed Clinical Criteria

For medical necessity clinical coverage criteria for deep brain and responsive cortical stimulation, refer to:

InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes (used by UnitedHealthcare to determine clinical coverage criteria)

Applicable Codes

Covered / Reference CPT codes for DBS and cortical neurostimulator proceduresCPTCovered

61867	Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site; first array
61868	Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site; each additional array (List separately in addition to primary procedure)
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
61889	Insertion of skull-mounted cranial neurostimulator pulse generator or receiver, including craniectomy or craniotomy, with connection to depth and/or cortical strip electrode array(s)
61891	Revision or replacement of skull-mounted cranial neurostimulator pulse generator or receiver with connection to depth and/or cortical strip electrode array(s)

Covered / HCPCS supply/device codesHCPCSCovered

L8679	Implantable neurostimulator, pulse generator, any type
L8680	Implantable neurostimulator electrode, each
L8682	Implantable neurostimulator radiofrequency receiver
L8685	Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
L8686	Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension
L8687	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
L8688	Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension

Removed CPT codes in recent revision (no longer listed)CPTNot Covered

61850	Removed from Applicable Codes list per 04/01/2026 revision
61860	Removed from Applicable Codes list per 04/01/2026 revision
61863	Removed from Applicable Codes list per 04/01/2026 revision
61864	Removed from Applicable Codes list per 04/01/2026 revision
64999	Removed from Applicable Codes list per 04/01/2026 revision

Provider Actions and Billing Notes

Documentation Required

Use InterQual criteria for medical necessity determination

Providers must document criteria consistent with InterQual to support coverage.

Billing Rule

Code listing is reference only

The listed procedure and diagnosis codes are provided for reference and do not guarantee coverage or reimbursement; benefit coverage is determined by the member-specific benefit plan and applicable laws.

61867
61868
61885
61886
61889
61891
L8679
L8680
L8682
L8685
L8686
L8687
L8688

Background and Evidence Summary

Deep brain stimulation devices typically consist of an implantable pulse generator (neurostimulator), one or more implantable leads with electrodes placed in select brain targets, and subcutaneous extension wires that connect the leads to the neurostimulator. The generator (similar in size to a cardiac pacemaker) is usually implanted near the clavicle or in the abdomen for some individuals, and DBS delivers electrical pulses to interrupt neural pathways responsible for abnormal movement or seizure activity.

The responsive cortical stimulation (RNS) system is a closed-loop implantable neurostimulator intended to detect abnormal electrical brain signals that precede seizures and deliver stimulation in response to normalize activity and prevent seizures. The RNS device includes a neurostimulator placed in the skull with leads positioned in seizure-originating brain areas; intended benefits include seizure prevention, potentially fewer adverse events than other neurostimulation methods, and remote data transmission to clinicians.

U.S. Food and Drug Administration information is provided for background and is informational only; FDA approval alone is not a basis for coverage. UnitedHealthcare may also use third-party tools such as InterQual® to assist in administering benefit determinations. (Policy revisions on 04/01/2026 updated applicable codes and supporting information.)

Evidence Topic	Summary
DBS proven indications	Dystonia; Essential tremor; Parkinson disease; Refractory focal/partial epilepsy — listed as proven and medically necessary indications for deep brain stimulation.
OCD evidence summary	Systematic reviews and randomized sham‑controlled trials show mixed results with generally low quality or small sample sizes; overall evidence considered insufficient/unproven for routine coverage of DBS for obsessive‑compulsive disorder.

Responsive cortical stimulation (RCS/RNS) is a closed-loop implantable neurostimulator that detects abnormal electrical brain signals that precede seizures and delivers electrical stimulation in response to try to normalize brain activity and prevent seizures before they fully develop. The device includes a neurostimulator placed in the skull with leads placed in the seizure-originating areas of the brain.