CurrentUnitedHealthcarePolicy 2025T0321JJ

Deep Brain and Cortical Stimulation

Defines UnitedHealthcare commercial and individual exchange medical policy coverage for deep brain stimulation (DBS) and responsive cortical stimulation (RNS), listing proven/medically necessary indications, unproven/not medically necessary indications, applicable coding, and references to InterQual criteria for clinical coverage details.

Policy Summary

PayerUnitedHealthcare

PolicyDeep Brain and Cortical Stimulation

Policy CodePolicy 2025T0321JJ

Change TypeTemplate Update (administrative)

Effective DateMay 1, 2025

Next Review Date

Key ActionWhen determining medical necessity for deep brain and responsive cortical stimulation, reference and apply InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes as the clinical criteria.

POLICY UPDATE CHANGES

Template Update: Created shared policy version to support application to Rocky Mountain Health Plans membership Application Individual Exchange; removed language indicating this Medical Policy does not apply to the state of Colorado; archived previous policy version 2025T0321II.

4Covered Indications (DBS and RNS proven)

1RNS proven indication

1Not medically necessary (OCD)

Coverage Summary

This UnitedHealthcare Commercial and Individual Exchange medical policy defines coverage for deep brain stimulation (DBS) and responsive cortical stimulation (RNS), listing proven/medically necessary indications and unproven/not medically necessary indications, applicable coding, and references to InterQual clinical criteria for medical necessity determinations.

The policy lists specific proven (medically necessary) indications for DBS and RNS and separately identifies indications considered unproven and not medically necessary (including OCD). It references InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes for detailed clinical coverage criteria and is intended to guide benefit determinations alongside member-specific plan documents.

Policy dates, identifiers, status, and quick stats

Effective dateMay 1, 2025

Last reviewMay 1, 2025

Next review

Policy number2025T0321JJ

StatusCURRENT

Covered Indications (DBS and RNS proven)4

RNS proven indication (partial/focal seizures)1

Explicitly listed not medically necessary indication (OCD)1

Medical Necessity Criteria

Medically Necessary (Proven) Indications for Deep Brain Stimulation

Deep brain stimulation is proven and medically necessary for treating the following indications:

ANY of the following

Dystonia
Essential tremor
Parkinson's disease
Refractory epilepsy for a partial or focal seizure disorder

Medically Necessary (Proven) Indications for Responsive Cortical Stimulation

Responsive cortical stimulation is proven and medically necessary for treating:

ANY of the following

Refractory partial or focal seizure disorder

Clinical Coverage Criteria Reference

For detailed medical necessity clinical coverage criteria:

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

Not Medically Necessary / Unproven Indications

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

ANY of the following

Deep brain stimulation and cortical stimulation for treating obsessive-compulsive disorder (OCD) and all other indications
Responsive cortical stimulation for treating all other indications

The policy states that the listed unproven indications are considered not medically necessary due to insufficient evidence of efficacy. This determination is supported by referenced evidence summaries, including InterQual criteria, the NICE recommendation that DBS for treatment‑resistant OCD should only be used in the context of research, and systematic reviews and randomized trials that report mixed or limited-quality evidence.

Coding

Relevant CPT / Unlisted procedureCPT

61886	Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array.
61889	Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays.
61891	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).
64999	Unlisted procedure, nervous system

Relevant HCPCS / Implantable neurostimulator and componentsHCPCS

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

Provider Actions

Documentation Required

Use InterQual criteria for medical necessity determinations

Reference and apply InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes when determining medical necessity for deep brain and responsive cortical stimulation.

InterQual® CP: Procedures, Stereotactic Introduction, Subcortical or Cortical Electrodes

Documentation Required

Member-specific benefit verification

Verify the member-specific benefit plan document and any applicable federal or state mandates prior to service; the member-specific benefit plan governs in the event of any conflict.

Billing Rule

Code reporting for unlisted procedures

When reporting services with an unlisted nervous system CPT code, include appropriate supporting documentation as required by the payer to justify the service.

64999

Background

Deep brain stimulation (DBS) delivers electrical pulses to selected brain targets (for example GPi, STN, or VIM) via surgically implanted electrodes connected to an implantable pulse generator (IPG) and extension leads. DBS aims to interrupt pathways responsible for abnormal movements in movement disorders and is reversible and adjustable, unlike permanent ablation.

Responsive cortical stimulation (RNS) employs a closed-loop implantable neurostimulator placed in the skull with leads in seizure-originating brain regions to detect abnormal electrical signals that precede seizures and deliver responsive stimulation to prevent seizures. Typical device components include the neurostimulator and intracranial leads; the IPG is roughly the size of a stopwatch and is often implanted near the clavicle or, in some patients, in the abdomen.

Definitions

Deep brain stimulation (DBS)Surgically implanted electrodes connected to an implantable pulse generator delivering electrical pulses to target brain areas to treat movement disorders and other conditions.

Responsive cortical stimulation (RNS)Closed-loop implantable neurostimulator programmed to detect abnormal electrical brain signals that precede seizures and deliver stimulation in response to prevent seizures.

The evidence summary in the policy references InterQual clinical coverage criteria for detailed medical necessity guidance and cites systematic reviews, randomized controlled trials, and guidance statements.

NICE concluded that evidence on DBS for chronic, severe, treatment‑resistant OCD is inadequate in quality and quantity and recommends DBS for this indication only in the context of research. Systematic reviews and some small RCTs provide mixed/limited quality evidence for DBS in OCD, while the policy notes stronger evidence supporting DBS for movement disorders and RNS for refractory focal (partial) epilepsy.

Revision History

05/01/2025revisedLatest

Policy Summary

PayerUnitedHealthcare

PolicyDeep Brain and Cortical Stimulation

Policy CodePolicy 2025T0321JJ

Change TypeTemplate Update (administrative)

Effective DateMay 1, 2025

Next Review Date

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