ModifiedUnitedHealthcarePolicy CS030IN.09

Deep Brain and Cortical Stimulation (for Indiana Only)

Medical policy governing use, coverage stance, and coding guidance for deep brain stimulation (DBS) and responsive cortical stimulation (RNS) for UnitedHealthcare members in Indiana; includes adult and pediatric distinctions and references InterQual criteria for clinical necessity.

Policy Summary

PayerUnitedHealthcare

PolicyDeep Brain and Cortical Stimulation (for Indiana Only)

Policy CodePolicy CS030IN.09

Change TypeMaterial revisions referencing InterQual and clarifying unproven indications

Effective DateJune 1, 2025

Next Review Date

Key ActionRefer adults (≥18) to InterQual CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes for medical necessity determination.

SourceLink

POLICY UPDATE CHANGES

For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes.

Deep brain stimulation and cortical stimulation for treating obsessive-compulsive disorder (OCD) and for all other indications not addressed in InterQual® criteria are unproven and not medically necessary.

Responsive cortical stimulation for treating all other indications not addressed in InterQual® criteria is unproven and not medically necessary.

Applicable codes section updated with notes regarding CPT code 61891 and removal of prior not-managed notations for certain CPT/HCPCS codes in Indiana.

Updated instructions to refer members under 18 years of age to InterQual® CP for medical necessity criteria for deep brain and responsive cortical stimulation.

18+Adult criteria age

Under 18Pediatric proven

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Responder rate (meta-analysis)

InsufficientRCS outside seizure disorders

Coverage Criteria

Age-specific coverage guidance

Coverage stance by age:

Adults (>=18): For medical necessity clinical coverage criteria for members 18 years of age and older, refer to the InterQual CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes.

Policy delegates clinical criteria to InterQual for adults.

Pediatrics (<18): Deep brain stimulation is proven and medically necessary for dystonia; essential tremor; Parkinson's disease; and refractory epilepsy for a partial or focal seizure disorder. Responsive cortical stimulation is proven and medically necessary for refractory partial or focal seizure disorder. For medical necessity clinical coverage criteria for deep brain and responsive cortical stimulation in members under 18, refer to the InterQual CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes.

Refer to InterQual for specific clinical coverage criteria for pediatric members.

Unproven / Not Medically Necessary Indications

Not medically necessary / unproven indications:

Unproven for adults and children: Deep brain stimulation and cortical stimulation for treating obsessive-compulsive disorder (OCD) and for all other indications not addressed in InterQual criteria are unproven and not medically necessary due to insufficient evidence of efficacy.

Responsive cortical stimulation is also unproven for indications not addressed in InterQual.

Coverage governed by InterQual® criteria

Policy guidance and coverage decisions are governed by InterQual® criteria where referenced.

InterQual-directed coverage: Medical necessity for deep brain and responsive cortical stimulation is determined by InterQual CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes; refer to InterQual for the specific clinical criteria used to evaluate requests.

Applies to members 18 years and older per policy; InterQual is referenced for clinical determinations.

Unproven / Not Medically Necessary

Explicit coverage stance for non-InterQual indications

Unproven/Not Medically Necessary Indications: Deep brain stimulation and cortical stimulation for treating obsessive-compulsive disorder (OCD) and for all other indications not addressed in InterQual® criteria are unproven and not medically necessary. Responsive cortical stimulation for indications other than partial or focal seizure disorders is insufficiently supported and is considered not medically necessary.

This reflects the policy revision effective 06/01/2025.

Based on the policy revision effective 06/01/2025, deep brain stimulation (DBS) and cortical stimulation for the treatment of obsessive-compulsive disorder (OCD) and for any other indications not addressed in the referenced InterQual® criteria are considered unproven and not medically necessary because there is insufficient evidence of efficacy. Providers should note that when InterQual® criteria are available for a given indication, those criteria govern medical necessity decisions for members aged 18 and older.

The policy states that responsive cortical stimulation (RCS/RNS) lacks sufficient evidence to support use for indications other than partial or focal seizure disorders. For non‑seizure indications, the evidence base is inadequate (few or no clinical studies), and therefore such uses are considered not medically necessary until well‑designed studies demonstrate safety and efficacy.

Restating the coverage stance: DBS and cortical stimulation for OCD, and for any indications not specified within the InterQual® Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes criteria, are not medically necessary due to insufficient evidence. Requests for these indications may be denied when they fall outside InterQual® guidance.

Alternate wording for operational use: Deep brain stimulation and cortical stimulation for the treatment of obsessive‑compulsive disorder (OCD) and for any other indications not addressed by InterQual® criteria are considered unproven and not medically necessary. Similarly, responsive cortical stimulation for indications other than partial/focal epilepsy is insufficiently supported and is considered not medically necessary.

Applicable Codes and Coding Guidance

Applicable CPT codes (part 1)CPT

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 (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array.
61864	…each additional array (List separately in addition to primary procedure).
61867	…stereotactic implantation with use of intraoperative microelectrode recording; first array.
61868	…each additional array with intraoperative microelectrode recording.
61885	Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array.

Applicable CPT/HCPCS codes (part 2)mixed

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).
64999	Unlisted procedure, nervous system.
L8679	Implantable neurostimator, 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.

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Applicable CPT/HCPCS codes and state notesmixed

61891	Revision or replacement of skull-mounted cranial neurostimulator pulse generator or receiver with connection to depth and/or cortical strip electrode array(s). — noted in policy as not managed for medical necessity review for Indiana at time of revision.
61850	Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical. — prior notation removed for Indiana.
61860	Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical. — prior notation removed for Indiana.
L8679	Implantable neurostimulator, pulse generator, any type. — prior notation removed for Indiana.

Provider Actions and Operational Notes

Prior Authorization

Prior Authorization and Code Management

Prior authorization requirements and code management vary by state and contract. Providers should reference UnitedHealthcare's most current Indiana Prior Authorization and Notification lists for up-to-date management status of CPT/HCPCS codes and prior authorization requirements.

Codes listed in this policy are for reference only and do not guarantee coverage or payment.
CPT code 61891 is not managed for medical necessity review in Indiana at the time this policy became effective; check the current Indiana prior authorization list for updates.
Codes labeled with an asterisk in the Applicable Codes section are not managed for medical necessity review for Indiana at the time this policy became effective.

Note

InterQual-Directed Requirements for Adults

For medical necessity clinical coverage criteria for stereotactic/subcortical or cortical electrode procedures in members 18 years and older (and for members under 18 where noted), InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes governs determinations. Providers should use the InterQual criteria as the primary clinical reference when submitting requests.

Background

Deep brain stimulation involves surgically implanted electrodes placed in specific subcortical targets (for example, subthalamic nucleus, globus pallidus internus, or other centers) connected to an implantable pulse generator; stimulation modulates dysfunctional neural circuits and is adjustable and reversible. Responsive cortical stimulation uses a skull‑mounted neurostimulator with leads positioned at seizure foci to detect abnormal electrical activity and deliver responsive stimulation to prevent seizure progression. When considering these technologies for coverage determinations, the policy delegates clinical necessity for adults (>=18 years) to the InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes; for pediatric cases, the policy also references InterQual® for specific criteria.

Definitions

Deep Brain Stimulation (DBS) — key characteristics

DefinitionSurgically implanted electrodes connected to an implantable pulse generator deliver electrical pulses to specific deep brain targets to modify abnormal movement-related pathways.

Typical TargetsInternal globus pallidus interna (GPi), subthalamic nucleus (STN), ventral intermediate nucleus (VIM) of the thalamus.

Device ComponentsImplantable pulse generator (IPG)/neurostimulator, implantable lead with electrodes, and subcutaneous extension wire(s).

Key CharacteristicsDBS is adjustable and reversible (unlike permanent ablation); electrode location depends on disorder treated.

Implant LocationNeurostimulator typically implanted near the clavicle or in the abdomen for younger individuals with primary dystonia.

Policy Summary

PayerUnitedHealthcare

PolicyDeep Brain and Cortical Stimulation (for Indiana Only)

Policy CodePolicy CS030IN.09

Change TypeMaterial revisions referencing InterQual and clarifying unproven indications

Effective DateJune 1, 2025

Next Review Date

Key ActionRefer adults (≥18) to InterQual CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes for medical necessity determination.

SourceLink

On This Page

InterQual-directed requirements apply for members 18 years of age and older.
InterQual CP should be consulted for clinical criteria used in medical necessity determinations for stereotactic/subcortical or cortical electrode procedures.

Documentation Required

Reference InterQual and Prior Authorization Lists

Reference both the InterQual criteria and UnitedHealthcare prior authorization lists when preparing authorizations and clinical documentation. The InterQual tool is used by UnitedHealthcare as an administration aid but does not replace state, federal, or contractual plan terms.

Submit clinical documentation supporting how member meets InterQual criteria alongside any required prior authorization forms.
Review the most current prior authorization and notification lists for Indiana for operational requirements.

Note

Reference Contractual and State Requirements

Federal, state, and contractual plan requirements may supersede this policy. Providers must check applicable plan documents and state-specific rules (including Indiana-specific prior authorization policies) before relying on this policy for coverage decisions.

In the event of a conflict, federal, state, or contractual requirements govern.
This policy is informational and may be modified; always verify current requirements.

Denial Risk

Denial Risk for Indications Outside InterQual Criteria

Requests for indications not addressed by InterQual criteria (for example, deep brain stimulation or cortical stimulation for OCD and other indications not covered by InterQual) may be considered not medically necessary and at risk for denial.

Deep brain stimulation and cortical stimulation for treating obsessive-compulsive disorder (OCD) are considered unproven and not medically necessary due to insufficient evidence for indications not addressed in InterQual.
Responsive cortical stimulation for indications not addressed in InterQual is considered not medically necessary.

Responsive Cortical Stimulation (RNS) — key characteristics

DefinitionA closed-loop implantable neurostimulator system placed in the skull with leads in seizure-originating brain areas that detects abnormal electrical signals and delivers stimulation in response to prevent seizures.

Intended BenefitsSeizure prevention, fewer adverse events than other neurostimulation methods, and remote data transmission to clinicians.

Device ComponentsSkull‑implanted neurostimulator and intracranial leads positioned in seizure foci.

MechanismDetects abnormal pre-seizure signals and delivers responsive stimulation to normalize electrical brain activity before seizures fully develop.

Responsive Cortical Stimulation (RCS) — evidence insufficiency for non‑seizure indications

Coverage StatementThere is insufficient evidence to support responsive cortical stimulation for indications other than partial or focal seizure disorders; such uses are considered unproven and not medically necessary.

Evidence GapLack of clinical studies for non-seizure indications; large well-designed studies are needed to establish safety, efficacy, and long-term outcomes.

Policy ImplicationRequests for RCS for non‑partial/focal seizure indications may be denied as not medically necessary due to insufficient evidence.

Deep Brain Stimulation (DBS) — subcortical targets and intended effects

DefinitionImplantation of electrodes in specific subcortical targets (e.g., subthalamic nucleus, nucleus accumbens) to modulate neural circuits for disorders such as refractory OCD and movement disorders.

Evidence for Psychiatric UseLevel I evidence (single class I study) supports bilateral subthalamic nucleus DBS for refractory OCD; Level II evidence (single class II study) supports bilateral nucleus accumbens DBS.

Mechanism and GoalAims to interrupt neural pathways responsible for abnormal behaviors or movements; electrode location varies by indication.

Contrast with AblationDBS is reversible and adjustable, unlike standard surgical ablation which causes permanent destruction.