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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that effective for services furnished on or after April 1, 2003, Medicare will cover unilateral or 
bilateral thalamic ventralis intermedius nucleus (VIM) deep brain stimulation (DBS) for the treatment of 
essential tremor (ET) and/or Parkinsonian tremor and unilateral or bilateral subthalamic nucleus (STN) or 
globus pallidus interna (GPi) DBS for the treatment of Parkinson's disease (PD) only under the following 
conditions: 
 
1. Medicare will only consider DBS devices to be reasonable and necessary if they are Food and Drug 
Administration (FDA) approved devices for DBS or devices used in accordance with FDA approved protocols 
governing Category B Investigational Device Exemption (IDE) DBS clinical trials. 
2. For thalamic VIM DBS to be considered reasonable and necessary, patients must meet all of the following 
criteria: 
 
a. Diagnosis of ET based on postural or kinetic tremors of hand(s) without other neurologic signs, or diagnosis 
of idiopathic PD (presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia)) which is of a 
tremor-dominant form. 
b. Marked disabling tremor of at least level 3 or 4 on the Fahn-Tolosa-Marin Clinical Tremor Rating Scale (or 
equivalent scale) in the extremity intended for treatment, causing significant limitation in daily activities 
despite optimal medical therapy. 
c. Willingness and ability to cooperate during conscious operative procedure, as well as during post-surgical 
evaluations, adjustments of medications and stimulator settings. 
 
3. For STN or GPi DBS to be considered reasonable and necessary, patients must meet all of the following 
criteria: 
 
a. Diagnosis of PD based on the presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia). 
b. Advanced idiopathic PD as determined by the use of Hoehn and Yahr stage or Unified Parkinson's Disease 
Rating Scale (UPDRS) part III motor subscale. 
c. L-dopa responsive with clearly defined "on" periods. 
d. Persistent disabling Parkinson's symptoms or drug side effects (e.g., dyskinesias, motor fluctuations, or 
disabling "off" periods) despite optimal medical therapy. 
e. Willingness and ability to cooperate during conscious operative procedure, as well as during post-surgical 
evaluations, adjustments of medications and stimulator settings. 
 
You can find this rule in the National Coverage Determination (NCD) - Deep Brain Stimulation for Essential 
Tremor and Parkinson's Disease (160.24) - Effective April 1, 2003. 
 
The rules say that deep brain stimulation is not reasonable and necessary and is not covered for ET or PD 
patients with any of the following: 
 
1. Non-idiopathic Parkinson's disease or "Parkinson's Plus" syndromes. 
2. Cognitive impairment, dementia or depression, which would be worsened by or would interfere with the 
patient's ability to benefit from DBS. 
3. Current psychosis, alcohol abuse or other drug abuse. 
4. Structural lesions such as basal ganglionic stroke, tumor or vascular malformation as etiology of the 
movement disorder. 
5. Previous movement disorder surgery within the affected basal ganglion. 
6. Significant medical, surgical, neurologic or orthopedic co-morbidities contraindicating DBS surgery or 
stimulation. 
 
You can find this rule in the National Coverage Determination (NCD) - Deep Brain Stimulation for Essential 
Tremor and Parkinson's Disease (160.24) - Effective April 1, 2003. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.