UnitedHealthcare deep brain cortical stimulation Coverage Update

Coverage Criteria and Determinations

Coverage stance and criteria

Covered status and routing instructions for deep brain stimulation (DBS) and cortical stimulation.

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

Policy defers to InterQual for adult clinical criteria; deep brain stimulation and/or cortical stimulation for obsessive-compulsive disorder (OCD) are designated unproven and not medically necessary in adults due to insufficient evidence.

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.

Refer to InterQual CP for specific pediatric medical necessity clinical coverage criteria.

OCD and other indications: Deep brain stimulation and cortical stimulation for treating obsessive-compulsive disorder (OCD) and for all other indications not listed as proven are unproven and not medically necessary due to insufficient evidence of efficacy.

Policy explicitly states DBS/RCS for OCD (adults) and other non‑listed indications are not medically necessary.

Adults - Coverage Determination

Adults (members 18 years of age and older): routing for medical necessity determinations.

Adults (>=18 years): Deep brain stimulation and/or cortical stimulation for treating obsessive-compulsive disorder (OCD) are considered unproven and not medically necessary due to insufficient evidence of efficacy.

For medical necessity clinical coverage criteria refer to InterQual CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes; document adherence to InterQual where applicable.

Pediatrics - Coverage Determination

Pediatric routing and covered indications for members under 18 years of age.

Members under 18: Refer to InterQual CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes for medical necessity clinical coverage criteria for deep brain and responsive cortical stimulation.

Deep brain stimulation is described as 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 described as proven and medically necessary for refractory partial or focal seizure disorder.

Deep brain stimulation and cortical stimulation for treating obsessive-compulsive disorder (OCD) and for all other indications not specified as proven are designated unproven and not medically necessary due to insufficient evidence of efficacy.

The National Institute for Health and Care Excellence (NICE) concluded that evidence on the safety and efficacy of DBS for chronic, severe, treatment‑resistant OCD in adults is inadequate in quality and quantity and therefore recommends that DBS should only be used in the context of research. NICE also recommends multidisciplinary patient selection, performance in specialized centers, and further randomized controlled trials to define targets, selection criteria, and outcomes.

UnitedHealthcare considers deep brain stimulation and/or cortical stimulation for OCD to be unproven and not medically necessary because the available studies are limited in size and design, heterogeneous in treatment planning and targets, and do not provide consistent randomized controlled data demonstrating sustained efficacy. As a result, these procedures for OCD (and for indications not established as proven) do not meet the evidence threshold required for medical necessity determinations.

The policy update adds explicit language that for members 18 years and older, DBS and cortical stimulation for OCD are considered unproven and not medically necessary due to insufficient evidence of efficacy. Systematic reviews and meta-analyses report mixed quality evidence, small sample sizes, and heterogeneity across studies, supporting the determination that further rigorous research is needed before routine coverage can be supported.

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for deep brain stimulation (DBS) and responsive cortical stimulation procedures. Submit a prior authorization request before scheduling services; reference the applicable procedure and supply codes when requesting review.

Prior authorization applies to CPT/HCPCS codes listed in the Applicable Codes section (e.g., 61850–61891, 64999; L8679–L8688).
Prior auth review will reference InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes for adult medical necessity determinations.

Denial Risk

High Denial Risk for DBS/Responsive Cortical Stimulation for OCD in Adults

For adults (age ≥ 18) DBS and/or cortical stimulation for obsessive‑compulsive disorder (OCD) are considered unproven and are not medically necessary due to insufficient evidence of efficacy. Requests for DBS or responsive cortical stimulation to treat OCD in members 18 years and older are at high risk for coverage denial.

Applicable Procedure and Device Codes

Procedure 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	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; 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 (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), 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 (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), 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

Procedure CPT and HCPCS codes (part 2 / device codes)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 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.

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DBS device FDA product codesmixed

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

Responsive cortical device FDA product codemixed

PFN	FDA product code referenced for responsive cortical devices

Background and Clinical Context

Deep brain stimulation (DBS) delivers continuous electrical pulses to specific subcortical brain targets (for example, internal globus pallidus, subthalamic nucleus, or ventral intermediate nucleus) via surgically implanted electrodes connected to an implantable pulse generator. Responsive cortical stimulation (RNS) is a closed‑loop implantable neurostimulator designed to detect abnormal electrical signals and deliver on‑demand stimulation to reduce seizure activity. Both technologies require surgical implantation and multidisciplinary management by teams experienced in neurosurgery, neurology, and relevant specialty care.

Definitions

inv-21: Deep Brain Stimulation (DBS) — definition and brief key points

DefinitionDeep brain stimulation (DBS): surgically implanted electrodes connected to an implantable pulse generator deliver ongoing electrical stimulation to subcortical brain targets (e.g., GPi, STN, VIM). The system is adjustable and reversible and includes leads, extension wires, and a neurostimulator (implantable pulse generator).

Primary purposeModulate abnormal neural pathways to reduce symptoms of movement disorders (e.g., Parkinson's disease, essential tremor) by delivering continuous electrical pulses to selected brain regions.

Device componentsImplantable pulse generator (neurostimulator), implantable lead(s) with electrodes, and subcutaneous extension wires connecting leads to the neurostimulator.

Key clinical pointDBS is reversible and adjustable, unlike ablative surgery which causes permanent destruction of targeted tissue.

Typical implant sitesExamples of targets include the internal globus pallidus interna (GPi), subthalamic nucleus (STN), and ventral intermediate nucleus (VIM) of the thalamus.

Policy Revision History

2025-05-01RevisionLatest

Added adult coverage rationale: directs reviewers to InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes and states DBS and/or cortical stimulation for obsessive-compulsive disorder (OCD) are unproven and not medically necessary for members 18 years and older.

2025-05-01Revision

Updated pediatric instruction to refer to InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes for medical necessity clinical coverage criteria for deep brain and responsive cortical stimulation.

2025-05-01Administrative

OpenPayer

Deep Brain and Cortical Stimulation (for Kentucky Only)