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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 20.2
Stereotactic Radiofrequency Pallidotomy With Microelectrode Mapping For Treatment Of Parkinson’s Disease
Issue Date:  July 8, 1998
Authority:  32 CFR 199.4(c)(2) and (c)(3)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Pallidotomy is a neurosurgical procedure involving a surgical lesion of the globus pallidus, which lies in the basal ganglia portion of the brain, with the aim of controlling one or more of the major symptoms of parkinsonism, including tremor, rigidity, and hypokinesia, in those patients who have not responded adequately to medical treatment.
Pallidotomy for Parkinson’s disease may be cost-shared when the patient has a diagnosis of idiopathic Parkinson’s disease.
4.1  Patients exhibiting signs of early dementia.
4.2  Elderly patients with very advanced disease, autonomic symptoms, severe speech impairment.
4.3  Patients with “Parkinson’s Plus” syndrome which mimic true Parkinson’s disease, e.g., postural instability, freezing, poor speech volume and swallowing difficulties.
November 1, 1996.
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