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MP 7.01.16 Stereotactic Radiofrequency Pallidotomy for the Treatment of Parkinson’s Disease

Medical Policy
Section
Surgery
 
Original Policy Date
5/30/97
Last Review Status/Date
Reviewed by consensus/4:2003
Issue
4:2003
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

Stereotactic radiofrequency pallidotomy is an ablative procedure during which a radiofrequency electrode is used to create thermal lesions within an anatomically and physiologically defined region of the globus pallidus. Pallidotomy is used to relieve the symptoms of Parkinson’s disease, a chronic, progressive degenerative disease of the central nervous system. Pallidotomy may be performed in two ways: using stereotactic techniques and monopolar electrode stimulation for identification of the target region; and using electrophysiologic microelectrode mapping of the target region in addition to stereotactic methods. The difference in performing pallidotomy with or without microelectrode mapping is in how the target in the posteroventral globus pallidus is identified.


Policy

Stereotactic radiofrequency unilateral pallidotomy may be considered medically necessary for patients who must meet all of the following selection criteria:

  • the patient has a diagnosis of idiopathic Parkinson’s disease;
  • the patient’s disease was previously responsive to levodopa therapy but is now medically intractable;
  • the patient has severe levodopa-induced dyskinesia or disease characterized particularly by severe bradykinesia, rigidity, tremor, or dystonia, or by marked “on-off” fluctuations;
  • the patient does not have evidence of dementia; and
  • the patient is fully informed of the risks and benefits of the surgery, including the specific mortality and morbidity experience of the center at which the procedure is to be performed.

Stereotactic bilateral radiofrequency pallidotomy is considered investigational.


Policy Guidelines

Pallidotomy is not generally recommended for elderly or severely debilitated patients, for patients who have significant cognitive deficits or who have medical conditions that would increase their risk of intracerebral hemorrhage.


Benefit Application

BlueCard/National Account Issues

No applicable information


Rationale

2002 Update
 
This policy was originally based on a 1996 TEC Assessment. (1) A literature review was performed on the MEDLINE database for the period of 1996 to July 2002. Several studies have reported minimal neuropsychological or psychiatric changes in those undergoing unilateral pallidotomy. (2-4) A few studies focusing on bilateral pallidotomy were identified. Merello and colleagues initiated a study that intended to randomize patients to bilateral pallidotomy or pallidotomy on one side, with deep brain stimulation of the globus pallidus on the contralateral side. The protocol was discontinued after the first 3 patients undergoing bilateral pallidotomy suffered severe adverse corticobulbar effects. (5) Intemann and colleagues reported that staged bilateral pallidotomy resulted in further improvements in some symptoms in a series of 11 patients, but there were significant adverse effects, including 5 patients with worsening of speech and memory. (6) Due to the potential for increased adverse outcomes with bilateral pallidotomy, it is likely that deep brain stimulation is preferable for bilateral procedures, either in combination with an initial pallidotomy followed by deep brain stimulation on the contralateral side, or bilateral deep brain stimulation. It should be noted that there have been no controlled trials comparing deep brain stimulation with pallidotomy.

References:

  1. 1996 TEC Assessment: Tab 18
  2. Green J, McDonald WM, Vitek JL et al. Neuropsychological and psychiatric sequelae of pallidtomy for PD: clinical trial findings. Neurology 2002;58(6):858-65.
  3. Rettig GM, York MK, Lai EC et al. Neuropsychological outcome after unilateral pallidotomy for the treatment of Parkinson’s disease. J Neurol Neurosurg Psychiatry 2000;69(3):326-36.
  4. Schmand B, de Bie RM, Koning-Haanstra M et al. Unilateral pallidotomy in PD: a controlled study of cognitive and behavioral effects. The Netherlands Pallidotomy Study (NEPAS) group. Neurology 2000;54(5):1058-64.
  5. Merello M, Starkstein S, Nouzeilles MI et al. Bilateral pallidotomy for treatment of Parkinson’s disease induced corticobulbar syndrome and psychic akinesia avoidable by globus pallidus lesion combined with contralateral stimulation. J Neurol Neurosurg Psychiatry 2001;71(5):611-4.
  6. Intemann PM, Masterman D, Subramanian I et al. Staged bilateral pallidotomy for treatment of Parkinson disease. J Neurosurg 2001;94(3):437-44.

 

Codes

Number

Description

CPT  61720  Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; globus pallidus or thalamus 
ICD-9 Procedure  01.42  Operations on globus pallidus 
ICD-9 Diagnosis  332.0  Paralysis agitans (includes Parkinson’s disease, idiopathic, etc.) 
  781.3  Dyskinesia 
  E936.4  Adverse effect of levodopa 
HCPCS  No Code   
Type of Service  Surgery 
Place of Service  Inpatient 


Index

Pallidotomy, Stereotactic Radiofrequency for Treatment of Parkinson’s Disease
Parkinson’s Disease, Stereotactic Radiofrequency Pallidotomy
Stereotactic Radiofrequency Pallidotomy for Treatment of Parkinson’s Disease


Policy History

Date Action Reason
5/30/97 Add to Surgery section New policy
10/08/02 Replace policy Policy reviewed with literature review; references to microelectrode mapping deleted since intraoperative technique was not relevant to policy considerations.
12/17/03 Replace policy Policy reviewed by consensus without literature review; no changes in policy.


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