CAM 70116

Stereotactic Radiofrequency Pallidotomy for the Treatment of Parkinson’s Disease

Category:Surgery   Last Reviewed:May 2018
Department(s):Medical Affairs   Next Review:May 2999
Original Date:May 1997    

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:

  1. Using stereotactic techniques and monopolar electrode stimulation for identification of the target region
  2. 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.
  • 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.

Rationale:
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 three 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 five 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.

Coding Section

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  
ICD-10-CM (effective 10/01/15) G20 Parkinson's disease
  G2111 Neuroleptic induced parkinsonism
  G2119 Other drug-induced secondary parkinsonism
  G218 Other secondary parkinsonism
  R270 Ataxia, unspecified
  R278 Other lack of coordination
  R279 Unspecified lack of coordination
Type of Service Surgery  
Place of Service Inpatient  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

05/21/2018 

Annual review, no change to policy intent. 

05/23/2017 

Annual review. No change to policy intent. 

05/04/2016 

Annual review, no change to policy intent. 

05/04/2015 

Annual review,no change to policy intent. Added coding.

05/05/2014

Annual review.  No change to policy intent. x


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