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TRICARE Policy Manual 6010.63-M, April 2021
Surgery
Chapter 4
Section 20.3
Stereotactic Radiofrequency Thalamotomy
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.
Revision:  
1.0  CPT CODE
61720
2.0  DESCRIPTION
Thalamotomy with microelectrode mapping is a neurosurgical procedure involving precision placement of a destructive lesion in the thalamus for relief of Parkinsonian resting tremor, intention tremor or dystonia.
3.0  POLICY
3.1  Benefits are covered for unilateral thalamotomy with microelectrode mapping for destructive lesion in the globus pallidus to treat disabling tremor from either Parkinson’s disease, intention tremor or dystonia when patients are no longer receptive to other treatments.
3.2  Indications for a thalamotomy are as follows:
3.2.1  Intention tremor:
3.2.1.1  Multiple sclerosis.
3.2.1.2  Post-traumatic.
3.2.1.3  Familial (Essential).
3.2.1.4  Post cerebrovascular accident (stroke).
3.2.2  Dystonia of arm or leg (also known as focal dystonias).
3.2.3  Dystonia musculorum deformans.
3.2.4  Post-traumatic dystonia.
3.2.5  Parkinsonism resting tremor.
3.3  Contraindications for a thalamotomy are as follows:
3.3.1  Dementia, memory or thought disturbance.
3.3.2  Poorly controlled high blood pressure.
3.3.3  Gait disturbance.
3.3.4  Significant speech problems.
4.0  EXCLUSIONS
4.1  Muscle resection for Parkinsonian tremor, intention tremor, or dystonia is unproven.
4.2  Rhizotomy for Parkinsonian tremor, intention tremor, or dystonia is unproven.
4.3  Selective peripheral denervation for Parkinsonian tremor, intention tremor, or dystonia is unproven.
4.4  Fetal tissue transplantation (embryonic mesencephalic transplantation) for Parkinsonian tremor, intention tremor, or dystonia is unproven.
5.0  EFFECTIVE DATE
October 1, 1995.
- END -

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