UnitedHealthcare DBS/Cortical Stimulation Coverage Update

Coverage and Medical Necessity Criteria

Adults (18 years and older) — Covered when InterQual CP criteria are met

Covered when InterQual CP criteria are met.

InterQual referral: Medical necessity for adults (>=18 years) is determined using InterQual CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes

Use InterQual criteria to define specific clinical requirements; applicable to members 18 years of age and older

Pediatrics (Under 18 years) — Deep brain stimulation proven and medically necessary for listed indications when documentation supports it

Deep brain stimulation is proven and medically necessary for the listed indications when appropriate clinical documentation supports it.

Pediatric approved indications: DBS is medically necessary for dystonia, essential tremor, Parkinson disease, and refractory epilepsy for a partial or focal seizure disorder in members under 18 years

Each indication requires documentation of diagnosis and medical necessity per policy; medical records must fully support the request

Unproven / Not Medically Necessary — Items considered unproven and not medically necessary due to insufficient evidence

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

Unproven indications: Deep brain stimulation and/or cortical stimulation for obsessive-compulsive disorder (OCD)

Considered unproven and not medically necessary due to insufficient evidence; requests may be denied

Other unproven indications: Deep brain stimulation and/or cortical stimulation for all other indications not specifically listed as proven and medically necessary in this policy

Requests for indications not listed as proven will be evaluated as unproven/not medically necessary per policy and Ohio Administrative Code 5160-101

Responsive cortical stimulation (RNS) is considered unproven and not medically necessary

Responsive cortical stimulation is listed as not medically necessary in the policy revisions

Coverage rationale and evidence synthesis — Coverage stance summarized from document excerpts

Coverage stance summarized from document excerpts.

DBS for OCD - evidence summary: Systematic reviews and pooled analyses report moderate reductions in Y-BOCS scores and variable responder rates for treatment-resistant OCD (short-term ~47% reduction; long-term responder rates reported up to ~70.7% in some series), with heterogeneity across studies and limited randomized data

References include Mar-Barrutia et al. 2021 and other systematic reviews

Guideline and regulatory position: NICE concludes evidence on safety and efficacy of DBS for chronic, severe, treatment-resistant OCD is inadequate and recommends use only in research settings with multidisciplinary selection

NICE April 28, 2021: patient selection by experienced multidisciplinary team and performance in centers with DBS expertise

Evidence level for specific targets: There is level I evidence (single class I study) supporting bilateral STN DBS and level II evidence supporting bilateral nucleus accumbens DBS for medically refractory OCD; insufficient evidence for unilateral DBS

Hamani et al. 2014 guideline summary

Deep brain stimulation (DBS) and cortical stimulation are explicitly listed in this policy as unproven and not medically necessary for the treatment of obsessive-compulsive disorder (OCD). The policy states these interventions lack sufficient evidence of efficacy to support coverage for OCD and for indications not otherwise identified in the policy as proven and medically necessary.

Requests for DBS or cortical stimulation for OCD (and for indications described as unproven) may therefore be denied as not medically necessary; providers should expect review of medical records to determine whether the requested service meets any applicable coverage exception or documented criteria.

Deep brain stimulation and/or cortical stimulation for treating obsessive-compulsive disorder are considered unproven and not medically necessary due to insufficient evidence of efficacy. This policy language clarifies that DBS/RNS are not covered for OCD except when an indication is specifically listed as proven and medically necessary elsewhere in the policy.

Policy history notes that the list of unproven indications was revised to explicitly include OCD and any other indications not listed as proven, reinforcing that coverage will not be supported for these uses under the current policy.

The policy identifies DBS and/or cortical stimulation for treating obsessive-compulsive disorder as unproven and not medically necessary because evidence does not adequately demonstrate clinical benefit. Requests for these procedures for OCD should be evaluated in light of this policy position and applicable state or contractual requirements.

The revision history emphasizes that responsive cortical stimulation and DBS for indications not listed as proven have been consolidated into the unproven/not medically necessary category, underscoring the policy’s more conservative coverage stance for these therapies.

Administrative revisions to the policy removed prior language describing responsive cortical stimulation as proven and medically necessary for refractory partial or focal seizure disorder. This change is documented in the policy history and reflects an update to the clinical coverage stance rather than a change to coding or procedural requirements.

Procedure and Device Codes

Procedure CPT 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; first array.
61864	...with stereotactic implantation... each additional array.
61867	...with use of intraoperative microelectrode recording; first array.
61868	...with use of intraoperative microelectrode recording; each additional array.
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 two 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).

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Device HCPCS 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.

FDA device product codes for DBSmixed

MHY	FDA product code referenced for deep brain stimulation devices
NHL	FDA product code referenced for deep brain stimulation devices
OLM	FDA product code referenced for deep brain stimulation devices
OLX	FDA product code referenced for deep brain stimulation devices

FDA device product codes for responsive cortical stimulationmixed

PFN	FDA product code referenced for responsive cortical devices

Prior Authorization, Documentation, and Selection

Prior Authorization

Prior Authorization Required (InterQual-based for Adults)

Prior authorization is required for adults (age 18 and over) and medical necessity for requests will be evaluated using the InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes. Providers must obtain prior authorization before scheduling services to avoid denial or delay.

Adults (≥18 years): InterQual-based prior authorization required
Follow payer-specific prior auth submission processes and timelines

Denial Risk

Documentation Requirement and Denial Risk

Medical records documentation must fully support the medical necessity of the requested services. Benefit coverage is governed by federal, state, contractual requirements, and applicable laws, and documentation may be requested to determine whether clinical criteria are met; documentation alone does not guarantee coverage.

Clinical Background

Deep brain stimulation (DBS) is a surgically implanted neuromodulation system that delivers electrical pulses to specific subcortical targets via implanted leads connected to an implantable pulse generator. DBS is intended to modulate abnormal neural circuits and is reversible and adjustable compared with ablative procedures.

Responsive cortical stimulation (RNS) is a closed-loop, skull‑mounted neurostimulator with leads placed in seizure-originating brain areas. The device is designed to detect abnormal electrical activity and deliver stimulation in response to those signals to help prevent seizures.

Both technologies require multidisciplinary patient selection, careful documentation of prior treatments, and detailed medical records to support medical necessity when coverage is considered.

Definitions and Key Terms

Deep brain stimulation (DBS) — definition and target examples

DefinitionDeep brain stimulation (DBS) is a surgically implanted system that delivers electrical pulses to specific subcortical targets (examples: internal globus pallidus interna [GPi], subthalamic nucleus [STN], ventral intermediate nucleus [VIM] of the thalamus) via implanted leads connected to an implantable pulse generator; DBS is reversible and adjustable compared with ablation.

System componentsTypical DBS system includes implanted lead(s) with electrodes, subcutaneous extension wire(s), and an implantable pulse generator or neurostimulator (approximately the size of a stopwatch).

Implant location examplesElectrode targets vary by disorder (examples: GPi for dystonia, STN for Parkinson disease, VIM for essential tremor).

Comparator to ablationUnlike surgical ablation, DBS does not permanently destroy the targeted area and allows adjustment of stimulation parameters over time.

Responsive cortical stimulation (RNS) — closed-loop neurostimulator definition

Policy Changes and Effective Dates

2026-05-01policy_revisionLatest

Revised clinical coverage criteria: removed language indicating responsive cortical stimulation is proven/medically necessary for refractory partial or focal seizure disorder; removed reference to the InterQual CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes; and expanded/clarified the list of unproven/not medically necessary indications to specify DBS and/or cortical stimulation are unproven for obsessive-compulsive disorder and for indications not listed as proven and medically necessary.

2026-05-01documentation_update

Added and clarified required medical records documentation language noting that documentation may be required to assess clinical criteria but does not guarantee coverage; specified required elements (history, physical exam, diagnostic test/procedure results), legibility, and availability upon request.

OpenPayer

Deep Brain and Cortical Stimulation (for Ohio Only)