Unilateral deep brain stimulation of the thalamus may be considered medically necessary in individuals with disabling, medically unresponsive tremor due to essential tremor or Parkinson disease.
Bilateral deep brain stimulation of the thalamus may be considered medically necessary in individuals with disabling, medically unresponsive tremor in both upper limbs due to essential tremor or Parkinson disease.
Unilateral or bilateral deep brain stimulation of the globus pallidus or subthalamic nucleus may be considered medically necessary in the following individuals:
· Those with Parkinson disease and ALL of the following:
o a good response to levodopa; AND
o motor complications not controlled by pharmacologic therapy; AND
o one of the following:
§ a minimum score of 30 points on the motor portion of the Unified Parkinson Disease Rating Scale when the patient has been without medication for approximately 12 hours OR
§ Parkinson disease for at least 4 years
· Individuals older than 7 years with chronic, intractable (drug-refractory) primary dystonia, including generalized and/or segmental dystonia, hemidystonia, and cervical dystonia (torticollis).
Deep brain stimulation for other movement disorders, including but not limited to tardive dyskinesia and post-traumatic dyskinesia, is considered investigational.
Deep brain stimulation for the treatment of chronic cluster headaches is considered investigational.
Deep brain stimulation for the treatment of other psychiatric or neurologic disorders, including but not limited to epilepsy, Tourette syndrome, depression, obsessive-compulsive disorder, anorexia nervosa, alcohol addiction, Alzheimer disease, multiple sclerosis tremor, and chronic pain, is considered investigational.
