CurrentUnitedHealthcarePolicy CS030TN.Q

Deep Brain and Cortical Stimulation (for Tennessee Only)

UnitedHealthcare Tennessee Medicaid/CoverKids medical policy governing coverage and medical necessity of deep brain stimulation (DBS) and responsive cortical stimulation (RNS) including proven indications, unproven indications, documentation requirements, and applicable procedure and device codes. Refers to InterQual CP criteria for specific clinical coverage criteria.

Policy Summary

PayerUnitedHealthcare

PolicyDeep Brain and Cortical Stimulation (for Tennessee Only)

Policy CodePolicy CS030TN.Q

Change TypeAdded coverage clarifications and documentation requirements

Effective DateApr 1, 2026

Next Review Date

Key ActionEnsure the patient's medical record contains legible documentation supporting medical necessity, including relevant history, physical exam, and pertinent diagnostic test results, and reference InterQual criteria when requesting approval.

POLICY UPDATE CHANGES

Added language clarifying deep brain stimulation and/or cortical stimulation are unproven and not medically necessary for treating obsessive-compulsive disorder (OCD) and all other indications not listed as proven and medically necessary.

Added language clarifying medical records documentation requirements to support medical necessity for requested services.

Updated Clinical Evidence and References sections to reflect current information.

4Proven Indications Listed

1RNS Intended Indication (epilepsy)

1Explicitly Not Covered (OCD)

Coverage Summary

Overview: This Tennessee Medicaid / CoverKids policy governs coverage and medical necessity of deep brain stimulation (DBS) and responsive cortical stimulation (RNS). Effective date: 2026-04-01; Last review: 2026-04-01. Coverage stance: mixed — several specific indications are listed as proven and medically necessary (DBS for dystonia, essential tremor, Parkinson disease, and refractory partial/focal epilepsy; RNS for refractory partial/focal seizure disorder), while other uses are considered unproven and not medically necessary (including DBS/cortical stimulation for obsessive-compulsive disorder and RNS or DBS for indications not listed). InterQual CP is referenced as the source for the detailed patient selection and clinical criteria.

Policy-level Key Facts

Policy NumberCS030TN.Q

SubjectDeep brain and responsive cortical stimulation

PayerUnitedHealthcare

Effective DateApril 1, 2026

Last ReviewApril 1, 2026

StatusCURRENT

Medical-Necessity Criteria

Medically Necessary / Proven Indications

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

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

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Coding

Relevant CPT / Unlisted Procedure CodesCPT

61850	Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical.
61860	Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical.
61863	Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site, without use of intraoperative microelectrode recording; first array.
61864	Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site, without use of intraoperative microelectrode recording; each additional array (List separately in addition to primary procedure).
61867	Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site, with use of intraoperative microelectrode recording; first array.
61868	Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site, with use of intraoperative microelectrode recording; each additional array (List separately in addition to primary procedure).
61885	Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array.
61886	Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays.
61889	Insertion of skull-mounted cranial neurostimulator pulse generator or receiver, including craniectomy or craniotomy, when performed, with direct or inductive coupling, 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).

1–10 of 11

1/2

Relevant HCPCS / Device CodesHCPCS

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.

Provider Actions

Documentation Required

Medical record documentation required

The patient's medical record must contain documentation that fully supports medical necessity for the requested services. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation supporting medical necessity should be legible, maintained in the patient's medical record, and must be made available upon request.

Medical record must include relevant history, physical exam, and results of pertinent diagnostic tests or procedures

Prior Authorization

Clinical criteria reference

Coverage determinations for deep brain and responsive cortical stimulation are subject to medical necessity clinical coverage criteria as defined in InterQual CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes. Providers must reference the InterQual criteria when requesting approval.

Background

Background: Deep brain stimulation (DBS) delivers electrical pulses to select subcortical brain areas via surgically implanted electrodes, with a device composed of an implantable pulse generator (neurostimulator), lead(s) with electrodes, and connecting wire(s). The mechanism is not completely understood, but the therapeutic intent is to interrupt pathways responsible for abnormal movements in movement disorders. Unlike ablative surgery, DBS is reversible and adjustable. Responsive cortical stimulation (RNS, a closed-loop implantable neurostimulator) is designed to detect abnormal brain signals that precede seizures and deliver stimulation in response to normalize activity and prevent seizures. The RNS system includes a skull‑placed neurostimulator and implanted leads and supports remote data transmission from the individual's home to clinicians.

Definitions: Deep brain stimulation (DBS) — electrical pulses delivered to select subcortical brain areas via surgically implanted electrodes; device includes pulse generator, leads, and connecting wire. Responsive cortical stimulation (RNS) — a closed-loop system intended to detect abnormal brain signals that precede seizures and deliver stimulation in response to normalize electrical activity and prevent seizures.

Definitions

Deep brain stimulation (DBS)Electrical pulses delivered to select subcortical brain areas via surgically implanted electrodes; device includes pulse generator, leads, and connecting wire; reversible and adjustable therapy

Responsive cortical stimulation (RNS)Closed-loop system that detects abnormal brain signals preceding seizures and delivers stimulation in response to normalize activity and help prevent seizures; includes skull‑placed neurostimulator and leads

Evidence & References

Evidence summary: The policy cites InterQual CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes as the source for the detailed clinical coverage criteria and directs providers to use InterQual for patient selection and prior authorization criteria. The supporting evidence base referenced in the policy includes multiple systematic reviews, randomized controlled trials, and other studies from 2021–2025 addressing DBS and RNS for conditions such as OCD, Parkinson disease, and epilepsy; detailed study summaries and references are included in the policy but clinicians should consult InterQual for the specific medical necessity criteria rather than attempting to reproduce study-level criteria here.

Revision History

04/01/2026added (material)Latest

Added language clarifying medical records documentation requirements to support medical necessity for requested services: coverage determined by federal, state, or contractual requirements; medical records must include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; documentation must be legible, maintained in the record, and made available upon request.