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National Coverage Determination (NCD)

Stereotactic Cingulotomy as a Means of Psychosurgery

160.4

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Tracking Information

Publication Number
100-3
Manual Section Number
160.4
Manual Section Title
Stereotactic Cingulotomy as a Means of Psychosurgery
Version Number
1
Effective Date of this Version
This is a longstanding national coverage determination. The effective date of this version has not been posted.
Ending Effective Date of this Version
12/18/2014
Implementation Date
Implementation QR Modifier Date

Description Information

Benefit Category
Inpatient Hospital Services
Physicians' Services


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

Cingulotomy is a psychosurgical procedure designed to interrupt the interconnecting neuronal pathways of the brain involved in the regulation of the emotions and certain autonomic functions. The intent of psychosurgery is to modify or alter disturbances of behavior, thought content, or mood that are not responsive to other conventional modes of therapy, or for which no organic pathological cause can be demonstrated by established methods.

The operation usually involves bilateral lesions that are placed in the anterior cingulum of the brain. Electrocautery probes are stereotactically inserted through lateral burr holes in the skull. A radio frequency pulsating current is used to ablate the tissue that connects the limbic system to the frontal lobe. Two or three repeat procedures may be performed in the same patient when a satisfactory result has not been achieved with the first cingulotomy.
Indications and Limitations of Coverage

Stereotactic cingulotomy is not covered under Medicare because the procedure is considered to be investigational.
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
Revision History
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Stereotactic Cingulotomy as a Means of Psychosurgery - RETIRED 3 04/10/2023 - 12/18/2014 View
Stereotactic Cingulotomy as a Means of Psychosurgery - RETIRED 2 12/18/2014 - 12/18/2014 View
Stereotactic Cingulotomy as a Means of Psychosurgery 1 01/01/1966 - 12/18/2014 You are here
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Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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