Contents:

Aneurysm, intracranial - Aneurysm, intracerebral, screening indications - Aneurysm embolization, intracranial Antibody testing for neurologic disease Autism and other pervasive developmental disorders - clinical guideline Back and Neck Disorders or Pain – refer to the Skeletal-Muscular section that follows CNS/Brain Tumors Cervical spine/spinal cord acute injuries Convectin-enhanced intraparenchymal delivery of drugs to the brain Electrical Stimulation Therapies in Neuromuscular Disorders - Deep brain/thalamic electrical stimulation for intractable tremors (Parkinson’s, dystonias, other tremors) refer to the Parkinson’s section that follows - Facial nerve paralysis (Bell’s palsy) - Cerebral palsy - Spinal cord injury - Stroke and other CNS Disorders - Cranial electrical stimulation/electrosleep therapy Neurology/Neurosurgery Studies – refer to guidelines throughout this and Radiology chapters for additional tests and diagnostic procedures - Autonomic Nervous System Function Testing - Brain death – diagnosis - Electroencephalogram (EEG) – std., ambulatory, sleep-deprived, surgical, - Brain mapping (quantitative EEG) - Electrocorticography (EcoG) EMG studies – also refer to the following Neurofeedback guideline - Electromyelogram (EMG)/Nerve Conduction Velocity (NCV) - Surface EMG, Spinoscopy - Electromyography, Anal or Urethral External Sphincter - Epiduroscopy - Neuromuscular junction testing by repetitive stimulation - Neuropsychological testing - Sensory Nerve Testing - Perception Threshold/Sensory Nerve Conduction Threshold (SNCT) - Sensory/Somatosensory Evoked Potentials - Visual and Auditory Evoked Response Tests Guillain-Barre syndrome (GBS): Therapy Headaches, migraine, tension, other - Cervico-occipital and cluster headaches – related procedures - Cranial Electrical Stimulation - Dihydroergotamine (DHE); Histamine desensitization therapies - Neuroimaging Studies for Headaches –Refer to the Radiology section Multiple Sclerosis (MS) – Diagnosis and Therapy Multiple Sleep Latency Test (MSLT) NeuroControl Freehand System Neurofeedback Training Neuropsychological Testing (NPT) – refer to the preceding guideline in the Neurology Studies section Percutaneous Neurotomy for Chronic Cervical Pain Sensory stimulation for coma patients Spasticity – Neurosurgical procedures - Selective peripheral denervation (Bertrand procedure) for spastic torticollis - Neurosurgical management of spasticity Spinal tap/lumbar puncture (LP), diagnostic Stereotactic cingulotomy Stereotaxic Depth Electrode Implantation Sympathetic therapy for chronic pain management – refer to DME chapter for guideline Sympathectomy, Thoracoscopic Carpal Tunnel Syndrome (CTS) - Conservative therapy - Low Level Laser Therapy for the Treatment of Carpal Tunnel Syndrome (CTS) - Carpal Tunnel Release Transient Ischemic Attack (TIA) – Hospitalization indications Trigeminal Neuralgia – Radiofrequency Ablation, Other therapies Parkinson’s disease - Deep brain/thalamic electrical stimulation for intractable tremors (Parkinson’s, dystonias, other tremors) - Pallidotomy for the treatment of Parkinson’s disease - Fetal tissue Cell (mesencephalic, adrenal-brain and fetal xenograft) transplantation for the treatment of Parkinson’s disease - Thalamotomy for movement disorders Seizures/Epilepsy – diagnosis and management - Electroencephalographic biofeedback for intractable seizures - Surgical evaluation for intractable seizure disorders – Grid Monitoring - Vagus Nerve Stimulation for the treatment of refractory seizures, depression Diabetic Neuropathy – refer to the preceding neurological testing section - Peripheral neuropathy with loss of protective sensation (LOPS) - H-wave stimulation for diabetic peripheral neuropathy with LOPS - Surgical decompression for diabetic neuropathy Cognitive Rehabilitation (CR) Sensory or auditory Integration Therapy/Training Constraint-induced movement therapy (CIMT) Head Injury – assessment and management Hippotherapy/Therapeutic Horseback Riding/Equestrian Therapy Hypothermia following acute brain injury Induced Lesions of Nerve Tracts, Medicare NCD Intra-operative Electromyographic Monitoring of Cranial Nerves Intraoperative Neurophysiologic Monitoring Invasive Intracranial Pressure Monitoring Shunt, subcutaneous lumbar Stroke prevention – Angioplasty of intracerebral arteries Stroke units Thalamotomy for movement disorders Ulnar Nerve Transposition, Decompression or Release Vagus Nerve Stimulation for the treatment of depression, seizures Vestibular – refer to ENT chapter Videopupillography/Tropicamide Drop Test Alzheimer’s Disease Ziconotide Intrathecal Infusion (Prialt®) for Severe Chronic Pain Neurology/Neurosurgery Referral Guideline Links Neurology/Neurosurgery Notes Back and Neck Pain – Evaluation and Procedures; Refer to Apollo’s Medical Review Criteria for Managing Care, DME chapter for additional related guidelines - Low back pain – evaluation and management introduction (‘acute’, ‘slow to recover’) - Algorithm for ‘slow to Recover’ back pain evaluation - Anterior Spinal Surgery, Endoscopic/Minimally Invasive - Artificial/Prosthetic Intervertebral Discs/Disc replacement - Cervical Spine – refer to related guidelines throughout this section - Cervical pain, acute, without preceding trauma – guideline - Cervical nerve root entrapment – surgical indications - Cervical Laminoplasty - Spinal Instability, cervical – lateral screw fixation - Chymopapain Chemonucleolysis - Endoscopic/Minimally Invasive Anterior Spinal Surgery- refer to Anterior Spinal Surgery - Epidural injections – steroids, nerve blocks – refer to spinal stenosis and the Anesthesiology section: Nerve blocks - Epidural adhesions – neurolysis - Facet Denervation: Neurotomy, Rhizotomy, or Articular Rhizolysis - Facet Denervation: Percutaneous Radiofrequency - Implantable Infusion Pumps for Chronic Severe Back Pain - Intervertebral Discs/Disc replacement – refer to ‘Artifical/prosthetic intervertebral discs’ - Intradiscal Electrothermal Therapy (IDET) - Laminectomy - Laser assisted spinal endoscopy - Machines to treat low back pain - Magnets for the treatment of chronic low back pain - Microdiscectomy, Percutaneous Lumbar Discectomy, automated - Neuroreflexotherapy (NRT) - NucleoplastyTM - Percutaneous vertebroplasty/kyphoplasty - Postural Reconstruction Physiotherapy - Prolotherapy - Scoliosis – Therapies - Spinal fusion/arthrodesis - Spinal Instability, lumbo-sacral – Pedicle screw fixation - Spinal stenosis - Interspinous distraction or dynamic stabilization for spinal stenosis (X-stop or Dynesys) - Surface electrical muscle stimulation for juvenile scoliosis- refer to guideline in DME chapter - Trigger Point Injections - Vertebroplasty, kyphoplasty – refer to percutaneous Neuroradiology Guidelines Spine – diagnostic radiology – Refer to CT and MRI sections that follow and the Skeletal-muscular chapter related topics - Low back pain imaging studies - Myelography and Cisternography - Discography - Scoliosis in children – indications for radiography - Videofluoroscopy of the spine (Motion X-rays, Dynamic Spinal Visualization) - Epidurogram/Epiduroscopy - Cervical spine; Diagnostic radiology; post-trauma Skull x-rays- post-trauma Diagnostic Arteriography/Angiography/Venography – Indications - Cervicocerebral angiography MRI/CT Overview CT Overview - Whole body CT Scans - CT angiography (CTA) - Computerized Tomography (CT or CAT) including headaches, extracranial head, brain, and thoracic scans; High-resolution CT (HRCT)for Pulmonary Studies MRI Overview including Standing and Sitting MRIs - MRI – Brain - MRI – Orbit, Face, and Neck -MRI – Spine - Magnetic Resonance Angiography (MRA) including Venography Neurovascular Imaging (update - Magnetic Resonance Neurography/Peripheral Nerves (MRN) - Magnetic Resonance Spectroscopy (MRS)/Nuclear Magnetic Resonance (NMR) - Magnetic Source Imaging (MSI)/Magnetoencephalography (MEG) Neuroimaging Studies for Headaches, Other Resources: Neuroimaging Alzheimer’s Disease 2007 – 55 page clinical guideline – contents list on page 2 of guideline ADHD 2007 – 53 page clinical guideline – contents list on page 2 of guideline References & Resources for Clinical Review Guideline Topics – Autism, Asperger, PDD Neurology and Neurosurgical web site resources

Summary:

This ‘single topic’ contains medical and surgical guidelines and benchmarks that may be useful for screening requests for payment authorization for care. Each must be reviewed by the medical policy committee of the health plan or contracted/delegated medical group, modified and then adapted as appropriate before implementation as review criteria. It is strongly recommended that all applicable documents that will be used to manage medical care in the organization be sent to affected providers for review and comment prior to implementation. This will always promote an understanding of the guideline or benchmark, avoid compliance issues, and frequently improve the document by additional input. Cost effective health care is quality driven (true quality, that is; not excessive care) and attention must always be focused on the issues that will result in optimal medical/surgical outcomes in a specific local medical environment.