Chapter 4
Section 20.3
Stereotactic
Radiofrequency Thalamotomy
Issue Date: July 8, 1998
Copyright: CPT only © 2006 American Medical
Association (or such other date of publication of CPT).
All Rights Reserved.
Revision:
1.0 CPT PROCEDURE 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.
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