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12465 Results

Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial electrothrombosis

Service Code
61708 (CPT) Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial electrothrombosis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intra-arterial embolization, injection procedure, or balloon catheter

Service Code
61710 (CPT) Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intra-arterial embolization, injection procedure, or balloon catheter
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anastomosis, arterial, extracranial-intracranial (eg, middle cerebral/cortical) arteries

Service Code
61711 (CPT) Anastomosis, arterial, extracranial-intracranial (eg, middle cerebral/cortical) arteries
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stereotactic Pallidotomy

Service Code
61720 (CPT) Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; globus pallidus or thalamus
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Stereotactic pallidotomy is a surgical technique used in the treatment of severe Parkinson’s disease. Pallidotomy is defined as the surgical creation of a lesion in a globus pallidus in the basal ganglia.

Exclusions

Stereotactic Pallidotomy is limited to one unit of servicea. Stereotactic pallidotomy is not covered when performed with radiation. This is considered investigational and is therefore non-covered by Medicaid.

Bilateral pallidotomy on the same date of service is not covered.

Stereotactic pallidotomy is not covered when any of the following conditions exist:

  • 1. Advanced cerebral atrophy, focal lesion, or lacuna of the basal ganglia.
  • 2. Advanced disease or other conditions that could explain the neurological

symptoms.

  • 3. Atypical Parkinson’s disorder.
  • 4. Dementia, cerebral atrophy, or confused state.

Place of Service

Inpatient.

How to Submit

N/A - No authorization is required

Resources

Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; subcortical structure(s) other than globus pallidus or thalamus

Service Code
61735 (CPT) Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; subcortical structure(s) other than globus pallidus or thalamus
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion;

Service Code
61750 (CPT) Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; with computed tomography and/or magnetic resonance guidance

Service Code
61751 (CPT) Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; with computed tomography and/or magnetic resonance guidance
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stereotactic implantation of depth electrodes into the cerebrum for long-term seizure monitoring

Service Code
61760 (CPT) Stereotactic implantation of depth electrodes into the cerebrum for long-term seizure monitoring
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stereotactic localization, including burr hole(s), with insertion of catheter(s) or probe(s) for placement of radiation source

Service Code
61770 (CPT) Stereotactic localization, including burr hole(s), with insertion of catheter(s) or probe(s) for placement of radiation source
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in addition to code for primary procedure)

Service Code
61781 (CPT) Stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in addition to code for primary procedure)

Service Code
61782 (CPT) Stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for primary procedure)

Service Code
61783 (CPT) Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); gasserian ganglion

Service Code
61790 (CPT) Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); gasserian ganglion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); trigeminal medullary tract

Service Code
61791 (CPT) Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); trigeminal medullary tract
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion

Service Code
61796 (CPT) Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure)

Service Code
61797 (CPT) Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion

Service Code
61798 (CPT) Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex (List separately in addition to code for primary procedure)

Service Code
61799 (CPT) Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)

Service Code
61800 (CPT) Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Deep Brain Stimulation (DBS)

Service Code
61850 (CPT) Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Deep brain stimulation (DBS) consists of electrical stimulation of specific sites in the brain with implanted electrodes to reduce the symptoms of movement disorders such as Parkinson’s disease and Essential Tremor. DBS can be done on one or both sides of the brain, depending on the disorder and the beneficiary's symptoms. Once implanted, noninvasive programming of the stimulator can be adjusted to the patient’s symptoms. This is an important feature for patients, whose disease may progress over time, requiring different stimulation parameters. Setting the best stimulation parameters may involve the balance between optimal symptom control and the appearance of side effects of stimulation, such as dysarthria, disequilibrium, or involuntary movements.

Limits

1 unit per date of service

Exclusions

DBS is contraindicated when any of the following are true:

  • a. Medical, surgical, neurologic, or orthopedic co-morbidities exist

contraindicating DBS surgery or stimulation.

  • b. One or more medical conditions exist that require repeated magnetic

resonance imaging (MRI). MRI can be safely performed under specialized protocols.

  • c. Cognitive impairment, dementia, or depression would be worsened by or

would interfere with the beneficiary’s ability to benefit from DBS.

  • d. Botulinum toxin injections have been given within the last 4 months.
  • e. Diathermy will be used in the future.

Place of Service

Inpatient, Outpatient, and Independent Diagnostic Testing Facilities (IDTF). CPT codes 95970, 95976 and 95977 may be billed in the office setting. CPT codes 95976 and 95977 may be billed in IDTF Centers.

How to Submit

N/A - No authorization is required

Resources