CurrentUnitedHealthcarePolicy CSNCT0321.06

Deep Brain and Cortical Stimulation (for North Carolina Only)

Policy governs coverage for deep brain stimulation (DBS) and responsive cortical stimulation (RNS) for members under UnitedHealthcare in North Carolina; it references state Medicaid and InterQual criteria for clinical necessity and notes specific non-covered indications.

Policy Summary

PayerUnitedHealthcare

PolicyDeep Brain and Cortical Stimulation (for North Carolina Only)

Policy CodePolicy CSNCT0321.06

Change TypeClarifiedAddedUpdated

Effective DateApr 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests and medical necessity documentation following InterQual CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes.

SourceLink

POLICY UPDATE CHANGES

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

Notation that HCPCS codes L8679, L8680, L8682, L8685, L8686, L8687, and L8688 are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.

Updated Description of Services and FDA sections to reflect the most current information.

NC-onlyGeographic applicability

DBS & RNSDevices/policies covered

7 HCPCSHCPCS codes noted as not on NC Medicaid fee schedule

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InterQualExternal criteria referenced

Coverage and Medical Necessity Criteria

Medical necessity (DBS and RNS)

Covered when ALL of the following are met (refer to InterQual CP for detailed clinical criteria):

InterQual-based clinical necessity: Medical necessity clinical coverage criteria for deep brain and responsive cortical stimulation are determined by the North Carolina Medicaid Clinical Coverage Policy (Physician: 1A-26) for DBS and by the InterQual CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes for DBS and RNS.

Providers must use the referenced InterQual CP and state Medicaid clinical coverage policy to establish medical necessity; this policy defers to those detailed criteria.

Unproven indications (RNS)

Not medically necessary / unproven:

Unproven indications: Responsive cortical stimulation for treating obsessive-compulsive disorder (OCD) and for all other indications beyond refractory partial or focal seizure disorder is considered unproven and not medically necessary due to insufficient evidence of efficacy.

Large, well-designed studies are needed to establish safety, efficacy, and long-term outcomes for these indications.

Responsive cortical stimulation has not been demonstrated to be effective for indications beyond refractory partial or focal seizure disorders. The policy states there is insufficient evidence to support use of responsive cortical stimulation for other conditions and notes that large, well-designed studies are needed to establish safety, efficacy, and long-term outcomes.

Responsive cortical stimulation for obsessive-compulsive disorder (OCD) and for all other non–partial/focal seizure indications is considered not medically necessary because current evidence is insufficient to demonstrate clinical benefit for these uses.

Applicable Procedure and HCPCS/CPT Codes

Applicable CPT codes (cortical)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.

Applicable CPT codes (subcortical/other)CPT

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.
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.
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.
64999	Unlisted procedure, nervous system.

Applicable HCPCS codes (note: not on NC Medicaid Fee Schedule)HCPCS

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.

Prior Authorization, Billing, and Documentation Requirements

Prior Authorization

Prior authorization per InterQual

Prior authorization determinations for deep brain stimulation (DBS) and responsive cortical stimulation should follow InterQual CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes for medical necessity review.

Documentation Required

Provider action / note

Providers should submit all required clinical documentation to support medical necessity determinations per InterQual and state-specific requirements. Ensure documentation clearly indicates diagnosis, prior treatments tried, and rationale for implantation or stimulation therapy.

Background and Service Description

Deep brain stimulation (DBS) delivers electrical pulses via surgically implanted electrodes to targeted subcortical brain regions (for example, the globus pallidus internus, subthalamic nucleus, or ventral intermediate nucleus) using an implantable pulse generator. The therapy is adjustable and reversible and is used to modulate neural circuits involved in movement and other neurologic disorders. The RNS System is a closed-loop implantable neurostimulator placed in the skull with leads in seizure-originating brain areas to detect abnormal electrical activity and deliver responsive stimulation to prevent seizures.

Device and Procedure Definitions

Deep brain stimulation (DBS)

DefinitionDeep brain stimulation (DBS) delivers electrical pulses to select subcortical brain areas via surgically implanted electrodes connected to an implantable pulse generator (neurostimulator).

Delivery method / device componentsSurgically implanted leads with electrodes, subcutaneous extension wires, and an implantable pulse generator (IPG) or neurostimulator (approximately size of a stopwatch; similar to a cardiac pacemaker).

Target brain regionsInternal globus pallidus interna (GPi), subthalamic nucleus (STN), and ventral intermediate nucleus (VIM) of the thalamus.

Therapy characteristicsTherapy is reversible and adjustable (unlike surgical ablation) and aims to interrupt pathways responsible for abnormal movements in movement disorders (e.g., Parkinson disease, essential tremor).

Responsive Cortical Stimulation (RNS)

Policy Summary

PayerUnitedHealthcare

PolicyDeep Brain and Cortical Stimulation (for North Carolina Only)

Policy CodePolicy CSNCT0321.06

Change TypeClarifiedAddedUpdated

Effective DateApr 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests and medical necessity documentation following InterQual CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes.

SourceLink

On This Page

Billing Rule

Coding alignment with procedure

Include appropriate procedure and diagnosis coding that corresponds to the listed CPT and HCPCS codes for implantation and related neurostimulator procedures. Verify codes against the member's benefit and state fee schedules before billing.

CPT codes: 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886, 64999
HCPCS codes: L8679, L8680, L8682, L8685, L8686, L8687, L8688 (see billing note below)

Denial Risk

PROVIDER ACTIONS

Claims using the following HCPCS codes may not be covered by the State of North Carolina Medicaid Program; verify coverage with the applicable state fee schedule before submission.

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

Responsive Cortical Stimulation (RNS) is a closed‑loop implantable neurostimulator system intended to detect abnormal electrical brain signals that precede seizures and deliver stimulation in response to normalize activity and prevent seizures from fully developing.

Device placementA neurostimulator is placed in the skull with leads positioned in the seizure‑originating areas of the brain.

Operation / functionalityThe system continuously monitors brain signals, detects patterns preceding seizures, delivers responsive stimulation, and can transmit data from the patient’s home to clinicians.

Intended benefitsSeizure prevention with potentially fewer adverse events than other neurostimulation methods and provision of ambulatory data for clinician review.