ModifiedUnitedHealthcarePolicy CS030KS.02

Deep Brain and Cortical Stimulation (for Kansas Only)

Medical policy governing deep brain stimulation (DBS) and cortical stimulation for members in Kansas, describing covered indications, not medically necessary indications, and references to InterQual criteria for adults.

Policy Summary

PayerUnitedHealthcare

PolicyDeep Brain and Cortical Stimulation (for Kansas Only)

Policy CodePolicy CS030KS.02

Change TypeMaterial revisions to coverage stance and criteria

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionSubmit comprehensive medical records to support medical necessity for prior authorization and be aware DBS/cortical stimulation for OCD is listed as not medically necessary.

SourceLink

POLICY UPDATE CHANGES

Added language to indicate deep brain stimulation and/or cortical stimulation for treating obsessive-compulsive disorder (OCD) are unproven and not medically necessary due to insufficient evidence of efficacy.

Removed language indicating responsive cortical stimulation is proven and medically necessary for treating refractory partial or focal seizure disorder.

Revised language pertaining to medical necessity clinical coverage criteria and revised list of unproven and not medically necessary indications to clarify DBS and/or cortical stimulation are unproven and not medically necessary for OCD and all other indications not listed as proven and medically necessary.

Added language clarifying medical records documentation requirements that medical records must fully support medical necessity and may be requested.

KansasGeographic applicability

Not MNOCD stance (adults)

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Coverage Determinations

Coverage summary

Coverage determinations summarized from policy text:

Adults (>=18): For medical necessity clinical coverage criteria, refer to the InterQual CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes.

Adults' clinical criteria are delegated to InterQual reference.

Adults - OCD: Deep brain stimulation and/or cortical stimulation for treating obsessive-compulsive disorder (OCD) are unproven and not medically necessary due to insufficient evidence of efficacy.

Explicit negative stance for OCD in adults.

Pediatrics (<18): Deep brain stimulation is proven and medically necessary for dystonia; essential tremor; Parkinson disease; and refractory epilepsy for a partial or focal seizure disorder.

Explicit pediatric covered indications.

Pediatrics - Not medically necessary: Deep brain stimulation and/or cortical stimulation for OCD and all other indications, and responsive cortical stimulation, are unproven and not medically necessary in members under 18 due to insufficient evidence.

Pediatric negative stance for other indications and RNS.

Unproven / Not Medically Necessary for OCD

Policy coverage stance summary

OCD coverage stance: Deep brain stimulation and/or cortical stimulation for treating obsessive-compulsive disorder (OCD) are unproven and not medically necessary due to insufficient evidence of efficacy.

Policy updated 05/01/2026 clarifying unproven status

Professional guideline evidence

Guideline and evidence context (informational only)

Guideline evidence: Hamani et al. (2014) reported level I evidence for bilateral subthalamic nucleus DBS and level II for bilateral nucleus accumbens DBS; however, overall bodies of evidence are limited by small sample sizes and heterogeneity.

Informational — policy considers overall evidence insufficient for coverage

Systematic review evidence: Mar-Barrutia et al. (2021) synthesized 40 studies (344 individuals) and reported mean Y-BOCS reductions of ~47% with long-term responder rates (≥35% reduction) around 70.7% in long-term reports, but noted heterogeneity and uncertainty about durability across individuals.

Informational only — does not change policy NMN stance for OCD

This policy addresses the use of deep brain stimulation (DBS) and cortical stimulation for neurologic and neuropsychiatric conditions. For members 18 years of age and older, adult medical necessity clinical coverage criteria are determined by reference to InterQual clinical criteria where applicable; however, the policy explicitly clarifies coverage stance for certain indications. For members under 18, the policy separately identifies proven and unproven indications. The document also specifies that services are subject to federal, state, or contractual requirements and that medical record documentation may be requested to support medical necessity determinations.

Deep brain stimulation and/or cortical stimulation for treating obsessive-compulsive disorder (OCD) are listed as unproven and not medically necessary due to insufficient evidence of efficacy; claims for these indications may therefore be denied.

The policy states that responsive cortical stimulation is considered unproven and not medically necessary in the contexts described, and the revision removed prior language that indicated responsive cortical stimulation was proven and medically necessary for refractory partial or focal seizure disorder.

In summary, deep brain stimulation and/or cortical stimulation for OCD and for indications not listed as proven are considered unproven and not medically necessary; the policy language was updated to clearly reflect that responsive cortical stimulation is also unproven and not medically necessary where specified.

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	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).
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; 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).

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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.

Referenced FDA product codes for DBS devicesmixed

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

Referenced FDA product code for responsive cortical stimulation devicesmixed

PFN	FDA product code referenced for responsive cortical devices

Prior Authorization, Documentation, and Operational Guidance

Prior Authorization

Prior Authorization and Coding Guidance

Prior authorization is required for deep brain stimulation (DBS) and cortical stimulation procedures. Providers should obtain prior authorization before scheduling services and submit complete clinical documentation to support medical necessity. Review of prior authorization requests may reference InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes when applicable.

Prior authorization required for DBS and cortical stimulation procedures
InterQual may be used as part of the medical necessity review
Include applicable procedure and diagnosis codes on the authorization request

Documentation Required

Required Medical Record Documentation

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. Documentation should be legible, maintained in the patient's medical record, and made available upon request. Insufficient or incomplete documentation can result in denial of the prior authorization request or claim.

Clinical Background and Scope

Deep brain stimulation delivers electrical pulses via implanted electrodes to targeted subcortical structures (for example, globus pallidus interna, subthalamic nucleus, or ventral intermediate nucleus) using an implanted pulse generator and extension leads; it is adjustable and reversible compared with ablative procedures. Responsive cortical stimulation (the RNS System) uses a skull‑mounted neurostimulator and leads placed over seizure‑originating cortex to detect abnormal electrical activity and deliver responsive stimulation. The policy updates dated 05/01/2026 clarify coverage positions and document that medical records may be requested to demonstrate that the requested neurostimulation meets clinical criteria and contractual or regulatory requirements.

Key Definitions

inv-21: Deep brain stimulation — definition and device components

DefinitionDeep brain stimulation (DBS) delivers electrical pulses to select areas of the brain via surgically implanted electrodes; it is reversible and adjustable compared with ablative surgery.

Device componentsThe DBS system consists of an implantable pulse generator (neurostimulator), implantable lead(s) with electrodes, and subcutaneous extension wires connecting the lead(s) to the neurostimulator.

Neurostimulator descriptionThe neurostimulator is approximately the size of a stopwatch and is similar to a cardiac pacemaker; typically implanted near the clavicle or in the abdomen for some younger patients.

TargetingElectrodes are placed in subcortical targets (e.g., internal globus pallidus interna, subthalamic nucleus, ventral intermediate nucleus of the thalamus) with exact location depending on the disorder treated.

inv-22: Responsive cortical stimulation — definition and device description