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«PacifiCare’s medical management guidelines represent the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. They are ...»

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Deep Brain Stimulation- Commercial Medical Management Guideline Kupsch A, Benecke R, MJ, et al. Pallidal deep-brain stimulation in primary generalized or segmental dystonia. N Engl J Med. 2006 Nov 9;355(19):1978-90.

Kupsch A, Klaffke S, KAA, et al. The effects of frequency in pallidal deep brain stimulation for primary dystonia. J Neurol. 2003 Oct;250(10):1201-5. Erratum in: J Neurol. 2004 Aug;251(8):1031.

Medtronic, Inc. [Internet] Activa Therapy. Available at:

http://www.medtronic.com/physician/activa/index.html. Accessed April 2009.

Medtronic, Inc. [Internet] Activa Therapy Clinical Summary. Available at:

http://www.medtronic.com/physician/activa/downloadablefiles/197935002.pdf. Accessed April 2009.

Mueller J, Skogseid IM, Benecke R, et al. Pallidal deep brain stimulation improves quality of life in segmental and generalized dystonia: Results from a prospective, randomized sham-controlled trial.

Mov Disord. 2008 Jan;23(1):131-4.

National Institute for Health and Clinical Excellence (NICE). IPG 188. Deep brain stimulation for

tremor and dystonia (excluding Parkinson's disease). August 2006. Available at:

http://www.nice.org.uk/nicemedia/pdf/ip/IPG188guidance.pdf. Accessed April 2009.

National Institute of Neurological Disorders and Stroke (NINDS) [Internet]. Parkinson's Disease

Information Page. Updated 12/07. Available at:

http://www.ninds.nih.gov/disorders/parkinsons_disease/parkinsons_disease.htm. Accessed April 2009.

National Institute of Neurological Disorders and Stroke (NINDS) [Internet]. Essential Tremor

Information Page. Updated 11/07. Available at:

http://www.ninds.nih.gov/disorders/essential_tremor/essential_tremor.htm. Accessed April 2009.

National Institute of Neurological Disorders and Stroke (NINDS) [Internet]. Dystonias Information Page. Updated 12/07. Available at: http://www.ninds.nih.gov/disorders/dystonias/dystonias.htm.

Accessed April 2009.

Pahwa R, Factor SA, Lyons KE, et al. Practice Parameter: treatment of Parkinson disease with motor fluctuations and dyskinesia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006 Apr 11;66(7):983-95.

Vercueil L, Pollak P, Fraix V, et al. Deep brain stimulation in the treatment of severe dystonia. J Neurol. 2001 Aug;248(8):695-700.

Deep Brain Stimulation- Commercial Medical Management Guideline Vidailhet M, Vercueil L, Houeto JL, et al. Bilateral, pallidal, deep-brain stimulation in primary generalised dystonia: a prospective 3 year follow-up study. Lancet Neurol. 2007 Mar;6(3):223-9.

Vidailhet M, Vercueil L, Houeto JL, et al. Bilateral deep-brain stimulation of the globus pallidus in primary generalized dystonia. N Engl J Med. 2005 Feb 3;352(5):459-67.

Weaver F, Follett K, Hur K, Ippolito D, Stern M. Deep brain stimulation in Parkinson disease: a metaanalysis of patient outcomes. J Neurosurg. 2005 Dec;103(6):956-67.

Zesiewicz TA, Elble R, Louis ED, et al. Practice parameter: therapies for essential tremor: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2005 Jun 28;64(12):2008-20.

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Deep Brain Stimulation- Commercial Medical Management Guideline Policy Reformatted including Coverage and Clinical Recommendations sections 2/18/2002 Contact Information For questions regarding this policy, send an email to the Medical Technology Interpretation Service at medical_drug_interpretation@uhc.com with the word "Medical" in the subject line.

Coding The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only. Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.

CPT Codes 61863 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, 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 (eg, 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 (eg, 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 (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; each additional array (List separately in addition to primary procedure) 61880 Revision or removal of intracranial neurostimulator electrodes 61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array 61886 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or





Deep Brain Stimulation- Commercial Medical Management Guideline

inductive coupling; with connection to two or more electrode arrays 95970 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (ie, cranial nerve, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming 95978 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour 95979 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; each additional 30 minutes after first hour (List separately in addition to code for primary procedure) HCPCS Codes L8680 Implantable neurostimulator electrode, each L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only L8682 Implantable neurostimulator radiofrequency receiver L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension L8689 External recharging system for battery (internal) for use with implantable neurostimulator, replacement only ICD9 Diagnosis Codes (Proven) 332.0 Paralysis agitans 333.1 Essential and other specified forms of tremor 333.6 Genetic torsion dystonia 333.79 Other acquired torsion dystonia 333.83 Spasmodic torticollis

Deep Brain Stimulation- Commercial Medical Management Guideline

333.89 Other fragments of torsion dystonia 723.5 Torticollis, unspecified ICD9 Diagnosis Codes (Unproven) 294.11 Dementia in conditions classified elsewhere with behavioral disturbance 300.3 Obsessive-compulsive disorders 301.4 Obsessive-compulsive personality disorder 307.23 Tourette's disorder 311 Depressive disorder, not elsewhere classified 312.30 Impulse control disorder, unspecified 332.1 Secondary Parkinsonism 340 Multiple sclerosis 345.0 Generalized nonconvulsive epilepsy (Incomplete code - additional digit required) 345.00 Generalized nonconvulsive epilepsy without mention of intractable epilepsy 345.01 Generalized nonconvulsive epilepsy with intractable epilepsy 345.1 Generalized convulsive epilepsy (Incomplete code - additional digit required) 345.10 Generalized convulsive epilepsy without mention of intractable epilepsy 345.11 Generalized convulsive epilepsy with intractable epilepsy 345.2 Epileptic petit mal status 345.3 Epileptic grand mal status 345.4 Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures (Incomplete code - additional digit required) 345.40 Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy 345.41 Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, with intractable epilepsy 345.5 Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures (Incomplete code - additional digit required) 345.50 Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy Deep Brain Stimulation- Commercial Medical Management Guideline 345.51 Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, with intractable epilepsy 345.6 Infantile spasms (Incomplete code - additional digit required) 345.60 Infantile spasms without mention of intractable epilepsy 345.61 Infantile spasms with intractable epilepsy 345.7 Epilepsia partialis continua (Incomplete code - additional digit required) 345.70 Epilepsia partialis continua without mention of intractable epilepsy 345.71 Epilepsia partialis continua with intractable epilepsy 345.8 Other forms of epilepsy and recurrent seizures (Incomplete code - additional digit required) 345.80 Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy 345.81 Other forms of epilepsy and recurrent seizures, with intractable epilepsy 345.9 Unspecified epilepsy (Incomplete code - additional digit required) 346.20 Variants of migraine, not elsewhere classified, without mention of intractable migraine without mention of status migrainosus 346.21 Variants of migraine, not elsewhere classified, with intractable migraine, so stated, without mention of status migrainosus 350.1 Trigeminal neuralgia 353.6 Phantom limb (syndrome) ICD9 Procedure Codes 02.93 Replacement of spinal disc 86.09 Other incision of skin and subcutaneous tissue 86.99 Other operations on skin and subcutaneous tissue This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation. Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.

Deep Brain Stimulation- Commercial Medical Management Guideline Confidential and Proprietary, © UnitedHealthcare, Inc. 2009 Deep Brain Stimulation- Commercial Medical Management Guideline TITLE: Dermatoscopy and Surveillance Photography for Detection of Melanoma Authorized By: Medical Management Guideline Committee

Adoption Date: 09/16/09 Revision Date:

Disclaimer This medical management guideline represents the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. It is based on the MMG committee's review of the available evidence as of the date of this medical management guideline.

This medical management guideline contains clinical practice and utilization criteria to assist professionals in PacifiCare’s medical management practice when making medical necessity determinations prior to, subsequent to, or concurrent with the provisions of health care services. This medical management guideline is intended to support consistent, appropriate medical necessity determinations, but it does not replace an individualized case-by-case review and medical necessity determination for each PacifiCare member.

Member benefit coverage and limitations may vary based on the member’s benefit plan.

This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation. Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.

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Description After evaluating relevant benefit document language (exclusions or limitations), refer to Coverage sections of this document to determine coverage.

This policy describes the use of dermatoscopy and surveillance photography for the detection of melanoma.

Dermatoscopy, also commonly referred to as dermoscopy is a magnification technique designed to allow dermatologists to visualize pigmented skin lesions more clearly than possible with the unaided eye. Surveillance photography is used to Dermatoscopy and Surveillance Photography for Detection of Melanoma - Commercial Medical Management Guideline detect changes in a skin lesion that may indicate development of melanoma or to detect new lesions that have characteristics of melanoma.

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