evekhm/cms_iom_500 huggingface dataset:
Proposed LCD - Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DL37729)
Limitations (not covered):Treatment of head or voice tremorBilateral thalamotomyAn advanced neurodegenerative conditionUnstable cardiac diseaseDepression sufficiently severe to compromise beneficiarys ability to provide informed consent and limit likely clinical benefit of the treatmentSevere cognitive impairment (such as may be defined by a score of <24 on the MiniMental State Examination)A skull density ratio (SDR) (the ratio of cortical to cancellous bone) <0.40MRI contraindicatedGeneral InformationAssociated InformationN/ASources of InformationN/ABibliographyTarsy D, Shih L. Surgical treatment of essentialtremor. http://www.uptodate.com/contents/surgical-treatment-of-essential-tremor. Accessed 3/7/2018.Louis ED. Treatment of medically refractory essential tremor.N Engl J Med.2016;375;8:792-793.FDA approval ExAblate Neuro. https://www.accessdata.fda.gov/cdrh_docs/pdf15/P150038a.pdf. Accessed 3/5/2018.Jeanmonod D, Werner B, Morel A, et al. Transcranial magnetic resonance imagingguided focused ultrasound: noninvasive central lateral thalamotomy for chronic neuropathic pain.Neurosurg Focus.2012;32(1):1-11.Lipsman N, Schwartz ML, Huang Y, et al. MR-guided focused ultrasound thalamotomy for essential tremor: a proof-of-concept study.Lancet Neurol.2013;12(5):462-468.Elias WJ, Huss D, Voss T, et al. A pilot study of focused ultrasound thalamotomy for essential tremor.N Engl J Med.2013;369:640-648.Wintermark M, Druzgal J, Huss DS, et al. Imaging findings in MR imaging-guided focused ultrasound treatment for patients with essential tremor.Am J Neuroradiol.2014;35(5):891-896.
Proposed LCD - Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DL37729)
Chang WS, Jung HH, Kweon EJ, Zadicario E, Rachmilevitch I, Chang JW. Unilateral magnetic resonance guided focused ultrasound thalamotomy for essential tremor: practices and clinicoradiological outcomes.J Neurol Neurosurg Psychiatry.2015;86(3):257-264.Huss DS, Dallapiazza RF, Shah BB, Harrison MB, Diamond J, Elias WJ. Functional assessment and quality of life in essential tremor with bilateral or unilateral DBS and focused ultrasound thalamotomy.Mov Disord.2015;30(14):1937-1943.Jung HH, Chang WS, Rachmilevitch I, Tlusty T, Zadicario E, Chang JW. Different magnetic resonance imaging patterns after transcranial magnetic resonanceguided focused ultrasound of the ventral intermediate nucleus of the thalamus and anterior limb of the internal capsule in patients with essential tremor or obsessive-compulsive disorder.J Neurosurg.2015;122:162-168.Gallay MN, Moser D, Rossi F, et al. Incisionless transcranial MR-guided focused ultrasound in essential tremor: cerebellothalamic tractotomy.J Ther Ultrasound.2016;4:5. DOI 10.1186/s40349-016-0049-8.Elias WJ, Lipsman N, Ondo WG, et al. A randomized trial of focused ultrasound thalamotomy for essential tremor.N Engl J Med.2016;375;8:730-739.Alterman RL. A trial of focused ultrasound thalamotomy for essential tremor.N Engl J Med.2016;375;22:2201-2203.Novitas LCD Services That Are Not Reasonable and Necessary (L35094).Noridian LCD Non Covered Services (L36219).First Coast Service Options LCD Noncovered Services (DL33777).Palmetto GBA LCD Non-Covered Category III CPT Codes (DL34555).
Proposed LCD - Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DL37729)
First Coast Service Options LCD Noncovered Services (DL33777).Palmetto GBA LCD Non-Covered Category III CPT Codes (DL34555).BCBSMA Policy Number 243. Magnetic Resonance-Guided Focused Ultrasound. https://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/243%20MRI-Guided%20Focused%20Ultrasound%20-%20MRgFUS%20prn.pdf. Accessed 2/1/2022.Aetna Policy Number 0153. Thalamotomy. http://www.aetna.com/cpb/medical/data/100_199/0153.html. Accessed 3/5/2018.UnitedHealthcare Guideline Number MPG043.05. Category III CPT Codes. UnitedHealthCareOnline.Category III CodesAnthem Policy Number MED.00057. MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications. https://www.empireblue.com/dam/medpolicies/ebcbs/active/policies/mp_pw_a050053.html. Accessed 2/1/2022.Ravikumar VK, Parker JJ, Hornbeck TS, et al. Cost-effectiveness of focused ultrasound, radiosurgery, and DBS for essential tremor.Mov Disord.2017;32(8):1165-1173.Kim M, Jung NY, Park CK, Chang WS, Jung HH, Chang JW. Comparative Evaluation of Magnetic Resonance-Guided Focused Ultrasound Surgery for Essential Tremor.Stereotact Funct Neurosurg.2017;95(4):279-286.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;64(12):2008-2020.Zesiewicz TA, Elble RJ, Louis ED, et al. Evidence-based guideline update: treatment of essential tremor: report of the Quality Standards subcommittee of the American Academy of Neurology.Neurology.2011;77(19):1752-1755.
Proposed LCD - Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DL37729)
Schuurman PR, Bosch DA, Bossuyt PM, et al. A comparison of continuous thalamic stimulation and thalamotomy for suppression of severe tremor.N Engl J Med.2000;342(7):461-468.
Proposed LCD - Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DL37729)
Chang JW, Chang KP, Lipsman N, et al. A prospective trial of magnetic resonance-guided focused ultrasound thalamotomy for essential tremor: results of the 2-year follow-up.ANN NEUROL2018;83:107-114.P.S. Fishman,W.J. Elias,P. Ghanouni, R. Gwinn, N. Lipsman, M. Schwartz, J. W. Chang, T. Taira, V. Krishna, A. Rezai, K. Yamada, K. Igase, R. Cosgrove, H. Kashima, M.G.Kaplitt, T.S. Tierney, and H.M. Eisenberg, "Neurological adverse event profile of magnetic resonance imaging-guided focused ultrasound thalamotomy for essential tremor,"Moy Disord, vol. 33, no. 5, pp. 843-847-, May 2018.Krishna V, Sammartino, F, Cosgrove R, et al.Tremor Outcomes Improve with Experience in Focused Ultrasound Thalamotomy. In press.Moosa S, Martnez-Fernndez R, Elias WJ, Del Alamo M, Eisenberg HM, Fishman PS. The role of high-intensity focused ultrasound as a symptomatic treatment for Parkinsons disease.Mov Disord. 2019;34(9):1243-1251. doi:10.1002/mds.27779Ahmed N, Gandhi D, Melhem ER, Frenkel V. MRI guided focused ultrasound-mediated delivery of therapeutic cells to the brain: A review of the state-of-the-art methodology and future applications.Front Neurol. 2021;12:669449. doi:10.3389/fneur.2021.669449Lin F, Wu D, Yu J, et al. Comparison of efficacy of deep brain stimulation and focused ultrasound in parkinsonian tremor: a systematic review and network meta-analysis.J Neurol Neurosurg Psychiatry. 2021;92(4):434-443. doi:10.1136/jnnp-2020-323656
Proposed LCD - Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DL37729)
Schreglmann SR, Krauss JK, Chang JW, Bhatia KP, Kgi G. Functional lesional neurosurgery for tremor: a systematic review and meta-analysis.J Neurol Neurosurg Psychiatry. 2018;89(7):717-726. doi:10.1136/jnnp-2017-316302Xu Y, He Q, Wang M, et al. Safety and efficacy of magnetic resonance imaging-guided focused ultrasound neurosurgery for Parkinsons disease: a systematic review.Neurosurg Rev. 2021;44(1):115-127. doi:10.1007/s10143-019-01216-yLennon JC, Hassan I. Magnetic resonance-guided focused ultrasound for Parkinsons disease since ExAblate, 2016-2019: a systematic review.Neurol Sci. 2021;42(2):553-563. doi:10.1007/s10072-020-05020-1Ge Y, Wang Z, Gu F, et al. Clinical application of magnetic resonance-guided focused ultrasound in Parkinsons disease: a meta-analysis of randomized clinical trials.Neurol Sci. 2021;42(9):3595-3604. doi:10.1007/s10072-021-05443-4Magara A, Bhler R, Moser D, Kowalski M, Pourtehrani P, Jeanmonod D. First experience with MR-guided focused ultrasound in the treatment of Parkinsons disease.J Ther Ultrasound. 2014;2(1):11. doi:10.1186/2050-5736-2-11Schlesinger I, Eran A, Sinai A, et al. MRI Guided Focused Ultrasound Thalamotomy for Moderate-to-Severe Tremor in Parkinsons Disease. Parkinsons Disease.; 2015.
Proposed LCD - Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DL37729)
Schlesinger I, Eran A, Sinai A, et al. MRI Guided Focused Ultrasound Thalamotomy for Moderate-to-Severe Tremor in Parkinsons Disease. Parkinsons Disease.; 2015.Zaaroor M, Sinai A, Goldsher D, Eran A, Nassar M, Schlesinger I. Magnetic resonanceguided focused ultrasound thalamotomy for tremor: a report of 30 Parkinsons disease and essential tremor cases.J Neurosurg. 2018;128(1):202-210. doi:10.3171/2016.10.jns16758Fasano A, Llinas M, Munhoz RP, Hlasny E, Kucharczyk W, Lozano AM. MRI-guided focused ultrasound thalamotomy in non-ET tremor syndromes.Neurology. 2017;89(8):771-775. doi:10.1212/WNL.0000000000004268Bond AE, Shah BB, Huss DS, et al. Safety and efficacy of focused ultrasound thalamotomy for patients with medication-refractory, tremor-dominant Parkinson disease: A randomized clinical trial.JAMA Neurol. 2017;74(12):1412-1418. doi:10.1001/jamaneurol.2017.3098Martnez-Fernndez R, Rodrguez-Rojas R, Del lamo M, et al. Focused ultrasound subthalamotomy in patients with asymmetric Parkinsons disease: a pilot study.Lancet Neurol. 2018;17(1):54-63. doi:10.1016/S1474-4422(17)30403-9Ito H, Fukutake S, Yamamoto K, Yamaguchi T, Taira T, Kamei T. Magnetic resonance imaging-guided focused ultrasound thalamotomy for Parkinsons disease.Intern Med. 2018;57(7):1027-1031. doi:10.2169/internalmedicine.9586-17
Proposed LCD - Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DL37729)
Iacopino DG, Gagliardo C, Giugno A. Preliminary experience with a transcranial magnetic resonance- guided focused ultrasound surgery system integrated with a 1.5- T MRI unit in a series of patients with essential tremor and Parkinsons disease.Neurosurg Focus. 2018;44.Fasano A, De Vloo P, Llinas M, et al. Magnetic resonance imaging-guided focused ultrasound thalamotomy in Parkinson tremor: Reoperation after benefit decay.Mov Disord. 2018;33(5):848-849. doi:10.1002/mds.27348Jung NY, Park CK, Kim M. The efficacy and limits of magnetic resonance guided focused ultrasound pallidotomy for Parkinsons disease: a phase I clinical trial.J Neurosurg. 2018:1-9.Sperling SA, Shah BB, Barrett MJ, et al. Focused ultrasound thalamotomy in Parkinson disease: Nonmotor outcomes and quality of life: Nonmotor outcomes and quality of life.Neurology. 2018;91(14):e1275-e1284. doi:10.1212/WNL.0000000000006279Ito H, Fukutake S, Yamamoto K, et al. Magnetic resonance imaging-guided focused ultrasound thalamotomy for Parkinsons disease with cardiac pacemaker: A case report.Mov Disord Clin Pract. 2018;5(3):339-340. doi:10.1002/mdc3.12578Gallay MN, Moser D, Rossi F, et al. MRgFUS pallidothalamic tractotomy for chronic therapy-resistant Parkinsons disease in 51 consecutive patients: Single center experience.Front Surg. 2019;6:76. doi:10.3389/fsurg.2019.00076Martnez-Fernndez R, Mez-Mir JU, Rodrguez-Rojas R, et al. Randomized trial of focused ultrasound subthalamotomy for Parkinsons disease.N Engl J Med. 2020;383(26):2501-2513. doi:10.1056/NEJMoa2016311
Proposed LCD - Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DL37729)
Yamamoto K, Ito H, Fukutake S, et al. Focused ultrasound thalamotomy for tremor-dominant Parkinsons disease: A prospective 1-year follow-up study.Neurol Med Chir (Tokyo). 2021;61(7):414-421. doi:10.2176/nmc.oa.2020-0370Food and Drug Administration. Exablate Model 4000 Types 1.0 and 1.1 System Summary of Safety and Effectiveness Data. December 16, 2018. Accessed 11/07/2022. https://www.accessdata.fda.gov/cdrh_docs/pdf15/P150038S006B.pdfNational Government Services, Inc. Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Tremor.LCDL37421. Revised effective date 4/01/2018. Accessed 11/07/2022.Pouratian N, Baltuch G, Elias WJ, Gross R. American Society for stereotactic and Functional Neurosurgery position statement on magnetic resonance-guided focused ultrasound for the management of essential tremor.Neurosurgery. 2020;87(2):E126-E129. doi:10.1093/neuros/nyz510Wisconsin Physicians Service Insurance Corp. Category III Codes. LCD L35490. Revised effective date 6/12/2022. Accessed 11/07/2022.Palmetto GBA. Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor.LCDL37761.Revised effective date 8/13/2020. Accessed 11/07/2022.CGS Administrators, LLC. Magnetic Resonance Guided Focused Ultrasound Surgery System (MRgFUS) for the treatment of neurologic conditions.LCDL37790. Revised effective date 6/12/2022. Accessed 11/07/2022.Parkinsons Disease. Medical Policy Bulletin 0307. Revised effective date 9/16/2022. Accessed 11/07/2022.MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications. Medical Policy MED.00057. Revised effective date 9/16/2022. Accessed 11/07/2022.
Proposed LCD - Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DL37729)
MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications. Medical Policy MED.00057. Revised effective date 9/16/2022. Accessed 11/07/2022.Blue Cross Blue ShieldLA. Magnetic Resonance-Guided Focused Ultrasound. Policy 00180. Revised effective date 1/10/2022. Accessed 11/07/2022.Blue Cross Blue ShieldNC. MRI-Guided Focused Ultrasound (MRgFUS). Medical Policy. Revised effective date 5/2022. Accessed 11/07/2022.Magnetic ResonanceGuided Focused Ultrasound. Medical Policy 7.01.109. Revised effective date 8/22/2022. Accessed 11/07/2022.Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation. Surgery Policy 139. Revised effective date 12/01/2021. Accessed 11/07/2022.Tufts Health Plan. Medical Necessity Guidelines: Noncovered Investigational Services. Revised effective date 10/01/2022. Accessed 11/07/2022.Wellmark. MRI-Guided High-Intensity Focused Ultrasound (MRgFUS) Ablation. Medical Policy 04.01.09. Revised effective date 1/2022. Accessed 11/07/2022.Deuschl G, Antonini A, Costa J, et al. European Academy of Neurology/Movement Disorder Society-European section guideline on the treatment of Parkinsons disease: I. invasive therapies.Mov Disord. 2022;37(7):1360-1374. doi:10.1002/mds.29066ECRI. ExAblate Neuro (InSightec, Inc.) for Treating Tremor-dominant Parkinson Disease. Plymouth Meeting (PA):2020 Jul 23. (Clinical Evidence Assessment).
Proposed LCD - Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DL37729)
ECRI. ExAblate Neuro (InSightec, Inc.) for Treating Tremor-dominant Parkinson Disease. Plymouth Meeting (PA):2020 Jul 23. (Clinical Evidence Assessment).Chou KL, Tarsey D. Device-assisted and lesioning procedures for Parkinson disease. UpToDate. Updated 10/13/2022. Accessed 11/07/2022. https://www.uptodate.com/contents/device-assisted-and-lesioning-procedures-for-parkinson-disease?search=deep%20brain%20stimulation%20parkinsons&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H3670506581Ghanouni P, Pauly KB, Elias WJ, et al. Transcranial MRI-Guided Focused Ultrasound: A Review of the Technologic and Neurologic Applications.AJR Am J Roentgenol. 2015;205:150.Na YC, Chang WS, Jung HH, et al. Unilateral magnetic resonance-guided focused ultrasound pallidotomy for Parkinson disease.Neurology. 2015;85:549.
Proposed LCD - Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DL37738)
CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1862(a)(1)(D) refers to limitations on items or devices that are investigational or experimental.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Coverage Indications, Limitations, and/or Medical NecessityThis LCD addresses use of Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for the treatment of idiopathic essential tremor (ET) patients including Tremor Dominant Parkinson's disease (TDPD) patients with medication-refractory tremor.MRgFUS unilateral thalamotomy is considered medically reasonable and necessary in patients with all four of the following criteria:medication refractory ET (defined as refractory to at least two trials of medical therapy, including at least one first-line agent)moderate to severe postural or intention tremor of the dominant hand or another nationally accepted clinical measure of tremor severitydisabling ET (defined by a score of 2 on any of the eight items in the disability subsection of the CRST or another nationally accepted clinical measure of tremor severity)not a candidate for DBS (e.g., advanced age, anticoagulant therapy, surgical comorbidities, or has failed Deep Brain Stimulation (DBS), but has no retained cranial implants)Limitations (not covered):
Proposed LCD - Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DL37738)
Limitations (not covered):Treatment of head or voice tremorBilateral thalamotomyAn advanced neurodegenerative conditionUnstable cardiac diseaseDepression sufficiently severe to compromise beneficiarys ability to provide informed consent and limit likely clinical benefit of the treatmentSevere cognitive impairment (such as may be defined by a score of <24 on the MiniMental State Examination)A skull density ratio (SDR) (the ratio of cortical to cancellous bone) <0.40MRI contraindicatedGeneral InformationAssociated InformationN/ASources of InformationN/ABibliographyTarsy D, Shih L. Surgical treatment of essential t tremor. http://www.uptodate.com/contents/surgical-treatment-of-essential-tremor. Accessed 3/7/2018.Louis ED. Treatment of medically refractory essential tremor.N Engl J Med.2016;375;8:792-793.FDA approval ExAblate Neuro. https://www.accessdata.fda.gov/cdrh_docs/pdf15/P150038a.pdf. Accessed 3/5/2018.Jeanmonod D, Werner B, Morel A, et al. Transcranial magnetic resonance imagingguided focused ultrasound: noninvasive central lateral thalamotomy for chronic neuropathic pain.Neurosurg Focus.2012;32(1):1-11.Lipsman N, Schwartz ML, Huang Y, et al. MR-guided focused ultrasound thalamotomy for essential tremor: a proof-of-concept study.Lancet Neurol.2013;12(5):462-468.Elias WJ, Huss D, Voss T, et al. A pilot study of focused ultrasound thalamotomy for essential tremor.N Engl J Med.2013;369:640-648.Wintermark M, Druzgal J, Huss DS, et al. Imaging findings in MR imaging-guided focused ultrasound treatment for patients with essential tremor.Am J Neuroradiol.2014;35(5):891-896.
Proposed LCD - Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DL37738)
Chang WS, Jung HH, Kweon EJ, Zadicario E, Rachmilevitch I, Chang JW. Unilateral magnetic resonance guided focused ultrasound thalamotomy for essential tremor: practices and clinicoradiological outcomes.J Neurol Neurosurg Psychiatry.2015;86(3):257-264.Huss DS, Dallapiazza RF, Shah BB, Harrison MB, Diamond J, Elias WJ. Functional assessment and quality of life in essential tremor with bilateral or unilateral DBS and focused ultrasound thalamotomy.Mov Disord.2015;30(14):1937-1943.Jung HH, Chang WS, Rachmilevitch I, Tlusty T, Zadicario E, Chang JW. Different magnetic resonance imaging patterns after transcranial magnetic resonanceguided focused ultrasound of the ventral intermediate nucleus of the thalamus and anterior limb of the internal capsule in patients with essential tremor or obsessive-compulsive disorder.J Neurosurg.2015;122:162-168.Gallay MN, Moser D, Rossi F, et al. Incisionless transcranial MR-guided focused ultrasound in essential tremor: cerebellothalamic tractotomy.J Ther Ultrasound.2016;4:5. DOI 10.1186/s40349-016-0049-8.Elias WJ, Lipsman N, Ondo WG, et al. A randomized trial of focused ultrasound thalamotomy for essential tremor.N Engl J Med.2016;375;8:730-739.Alterman RL. A trial of focused ultrasound thalamotomy for essential tremor.N Engl J Med.2016;375;22:2201-2203.Novitas LCD Services That Are Not Reasonable and Necessary (L35094).Noridian LCD Non Covered Services (L36219).First Coast Service Options LCD Noncovered Services (DL33777).Palmetto GBA LCD Non-Covered Category III CPT Codes (DL34555).
Proposed LCD - Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DL37738)
First Coast Service Options LCD Noncovered Services (DL33777).Palmetto GBA LCD Non-Covered Category III CPT Codes (DL34555).BCBSMA Policy Number 243. Magnetic Resonance-Guided Focused Ultrasound.https://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/243%20MRI-Guided%20Focused%20Ultrasound%20-%20MRgFUS%20prn.pdf.Accessed 2/1/2022.Aetna Policy Number 0153. Thalamotomy. http://www.aetna.com/cpb/medical/data/100_199/0153.html. Accessed 3/5/2018.UnitedHealthcare Guideline Number MPG043.05. Category III CPT Codes. UnitedHealthCareOnline.Category III CodesAnthem Policy Number MED.00057. MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications.https://www.empireblue.com/dam/medpolicies/ebcbs/active/policies/mp_pw_a050053.html.Accessed 2/1/2022.Ravikumar VK, Parker JJ, Hornbeck TS, et al. Cost-effectiveness of focused ultrasound, radiosurgery, and DBS for essential tremor.Mov Disord.2017;32(8):1165-1173.Kim M, Jung NY, Park CK, Chang WS, Jung HH, Chang JW. Comparative Evaluation of Magnetic Resonance-Guided Focused Ultrasound Surgery for Essential Tremor.Stereotact Funct Neurosurg.2017;95(4):279-286.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;64(12):2008-2020.Zesiewicz TA, Elble RJ, Louis ED, et al. Evidence-based guideline update: treatment of essential tremor: report of the Quality Standards subcommittee of the American Academy of Neurology.Neurology.2011;77(19):1752-1755.
Proposed LCD - Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DL37738)
Schuurman PR, Bosch DA, Bossuyt PM, et al. A comparison of continuous thalamic stimulation and thalamotomy for suppression of severe tremor.N Engl J Med.2000;342(7):461-468.