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Clinical Policy Bulletin:
Stereotactic Cingulotomy
Number: 0288


Policy

Aetna considers stereotactic cingulotomy medically necessary when it is used as a last resort to provide pain relief for members with terminal cancer pain.

Aetna considers stereotactic cingulotomy experimental and investigational for the following indications (not an all inclusive list) because its effectiveness (including long-term outcomes) for these indications has not been established.

  • Treatment of chronic, intractable non-malignant pain (e.g., post-stroke pain)
  • Treatment of drug addiction
  • Treatment of psychiatric disease (e.g., affective disorders, aggressive behavior, anxiety, depression, obsessive-compulsive disorders, personality disorders, schizophrenia, and Tourette's disorder).


Background

Since its inception, functional neurosurgery (or psychosurgery) has been over-shadowed by ethical questions and doubts resulting from inadequate reporting of outcomes.  In the 1940s and early 1950s prior to the introduction of major psychotropic agents, psychosurgery became popular in the United States.  Pre-frontal lobotomies were indiscriminately performed for intractable mental illness, in particular, depression, anxiety, and obsessive-compulsive disorders (OCDs).  However, its side effects, especially the “frontal lobe syndrome”, led to the need for more refined surgical approaches; the most important of these was the use of stereotaxis.  Cingulotomy, subcaudate tractotomy, limbic leucotomy, and anterior capsulotomy are generally the stereotactic treatments of choice today.

MRI-guided stereotactic cingulotomy consists of lesioning the white matter deep to the cingulate gyrus.  Reports suggest that pain secondary to cancer is relieved in 30 % to 90 % of patients following cingulotomy or cingulotomy combined with midbrain tractotomy.  This procedure seems to be of most benefit when there is a major element of suffering.  The results have been less encouraging in non-malignant chronic pain, but it has been suggested that cingulotomy may be useful in cases in which depressive symptoms dominate the clinical picture.

The literature on the use of neuroablative procedures performed on the brain is non-existent in regards to chronic non-malignant pain, and limited in regards to psychiatric illnesses.  Most available studies are limited by the use of retrospective designs, variations in diagnostic systems, the lack of independent clinical raters, use of a variety of psychosurgical techniques, and the lack of true control groups.  Such irreversible, modern psychosurgical techniques performed on the brain in an effort to affect the psyche require prospective long-term follow-up studies to further define the role of surgery in treating various intractable psychiatric disease.

Jung et al (2006) examined the long-term effectiveness and adverse cognitive effects of stereotactic bilateral anterior cingulotomy as a treatment for patients with refractory OCD.  A total of 17 patients suffering from refractory OCD underwent stereotactic bilateral anterior cingulotomies and were followed for 24 months.  The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Clinical Global Impression and other neuropsychological tests were used to evaluate the effectiveness and cognitive changes of cingulotomy.  The tests were taken before and 12 and 24 months after surgery.  The mean improvement rate of the Y-BOCS score achieved from the baseline was 48 %.  Eight patients (47 %) met the responder criteria.  During the 24-month follow-up, there were no significant adverse effects observed after surgery.  The authors concluded that bilateral anterior cingulotomy was effective for the treatment of refractory OCD, and no other significant adverse cognitive effects on long-term follow-up were found.  The success rate in this study was fair and its findings need to be validated by well-designed studies.

Brotis et al (2009) stated that stereotactic cingulotomy constitutes a psycho-surgical procedure nowadays advocated in the treatment of medically intractable OCD, chronic pain and drug addiction.  From its theoretical conception to the first cingulectomies performed and modern stereotactic-guided cingulotomies, various target localization methods, different surgical techniques, and numerous lesioning devices have been utilized.  These investigators performed a literature review related to cingular lesion placement in an effort to identify misconceptions of the past, recapitulate existing knowledge and recognize targets for further research.  The initial animal and human electrophysiologic experimental data regarding the role of the cingulate cortex in various behavioral and cognitive functions were meticulously reviewed.  The clinical indications, surgical technique and the clinical results and complications of open cingulectomies were examined.  The anatomic target localization methodologies, surgical technique, and the outcome of the initial stereotactic cingulotomy procedures were reviewed, and the evolution of the imaging techniques, stereotactic devices, and lesioning strategies were followed.  The modern advanced surgical techniques, clinical outcome and the procedure-associated complications were analyzed with particular emphasis on the emotional, behavioral, and cognitive procedure-induced changes.  The authors concluded that large-scale prospective studies with strict inclusion and well-defined, objective outcome criteria are needed for defining the role of stereotactic cingulotomy in the current psycho-surgical armamentarium.

Jimenez et al (2012) performed a preliminary study on the safety and effectiveness of bilateral cingulotomy and anterior capsulotomy in patients with aggressive behavior.  Twenty-three psychiatric patients showing aggressive behavior refractory to conventional treatment were initially evaluated.  The subjects were clinically selected using the Overt Aggression Scale (OAS) and the Global Assessment of Functioning Scale (GAF).  Each case was carefully reviewed by the Ethics Committee of Mexico's General Hospital.  Once selection criteria were met, stereotactic lesions were made using radiofrequency on the anterior limb of the internal capsule and supragenual cingulum.  Statistical differences were evaluated with a Wilcoxon test at 6 months and at 4 years.  A total of 10 patients underwent surgery.  Their OAS and GAF scores decreased after the procedure at the 6-month (p < 0.05) and at the 4-year (p = 0.068) follow-up; 4 patients showed mild and transitory post-surgical complications (hyperphagia and somnolence).  The authors concluded that bilateral anterior capsulotomy in combination with cingulotomy may reduce aggressive behavior and improve clinical evaluations.  Very strict clinical and ethical evaluations were applied prior to considering patients for this treatment.  These preliminary findings were confounded by the combinational use of cingulotomy and capsulotomy.  Well-designed studies are needed to confirm the effectiveness of cingulotomy in the treatment of individuals with aggressive behavior.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
61720
61735
ICD-9 codes covered if selection criteria are met:
V66.7 Encounter for palliative care [terminal care]
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
295.00 - 295.95 Schizophrenic disorders
296.00 - 296.99 Episodic mood disorders
300.00 - 300.09 Anxiety, dissociative and somatoform disorders
300.3 Obsessive-compulsive disorders
300.4 Dysthymic disorder
301.0 - 301.9 Personality disorders
304.00 - 304.93 Drug dependence
307.23 Gilles de la Tourette's disorder
311 Depressive disorder, not elsewhere classified
338.21 - 338.29 Chronic pain
338.4 Chronic pain syndrome
Other ICD-9 codes related to the CPB:
338.3 Neoplasm related pain (acute) (chronic) [terminal]


The above policy is based on the following references:
  1. Laitinen LV. Psychosurgery today. Acta Neurochir Suppl (Wien). 1988;44:158-162.
  2. Pillay PK, Hassenbusch SJ. Bilateral MRI-guided stereotactic cingulotomy for intractable pain. Stereotact Funct Neurosurg. 1992;59:33-38.
  3. Wong ET, Gunes S, Gaughan E, et al. Palliation of intractable cancer pain by MRI-guided cingulotomy. Clin J Pain. 1997;13(3):260-263.
  4. Spangler WJ, Cosgrove GR, Ballantine HT Jr, et al. Magnetic resonance image-guided stereotactic cingulotomy for intractable psychiatric disease. Neurosurgery. 1996;38(6):1071-1076; discussion 1076-1078.
  5. Jenike MA. Neurosurgical treatment of obsessive-compulsive disorder. Br J Psychiatry Suppl. 1998; 35:79-90.
  6. Korzenev AV, Shoustin VA, Anichkov AD, et al. Differential approach to psychosurgery of obsessive disorders. Stereotact Funct Neurosurg. 1997;68(1-4 Pt 1):226-230.
  7. Meneses MS, Arruda WO. Magnetic resonance image-guided stereotactic cingulotomy for intractable psychiatric disease [letter; comment]. Neurosurgery. 1998;42(2):432-433.
  8. Balasubramaniam V. Magnetic resonance image-guided stereotactic cingulotomy for intractable psychiatric disease [letter]. Neurosurgery. 1997;40(5):107-108.
  9. Baer L, Rauch SL, Ballantine HT Jr, et al. Cingulotomy for intractable obsessive-compulsive disorder. Prospective long-term follow-up of 18 patients. Arch Gen Psychiatry. 1995;52(5):384-392.
  10. Baer L, Rauch SL, Jenike MA, et al. Cingulotomy in a case of concomitant obsessive-compulsive disorder and Tourette's syndrome [letter]. Arch Gen Psychiatry. 1994;51(1):73-74.
  11. Mindus P. Present-day indications for capsulotomy. Acta Neurochir Suppl (Wien). 1993;58:29-33.
  12. Jenike MA, Baer L, Ballantine T, et al. Cingulotomy for refractory obsessive-compulsive disorder. A long-term follow-up of 33 patients. Arch Gen Psychiatry. 1991;48(6):548-555.
  13. Diering SL, Bell WO. Functional neurosurgery for psychiatric disorders: A historical perspective. Stereotact Funct Neurosurg. 1991;57(4):175-194.
  14. Hassenbusch SJ, Pillay PK, Barnett GH. Radiofrequency cingulotomy for intractable cancer pain using stereotaxis guided by magnetic resonance imaging. Neurosurgery. 1990;27(2):220-223.
  15. Kurlan R, Kersun J, Ballantine HT Jr, et al. Neurosurgical treatment of severe obsessive-compulsive disorder associated with Tourette's syndrome. Mov Disord. 1990;5(2):152-155.
  16. Martuza RI, Chiocca FA, Jenike MA, et al. Stereotactic radiofrequency thermal cingulotomy for obsessive compulsive disorder. J Neuropsychiatry Clin Neurosci. 1990;2(3):331-336.
  17. Bouckoms AJ. Ethics of psychosurgery. Acta Neurochir Suppl (Wien). 1988;44:173-178.
  18. Ballantine HT Jr, Bouckoms AJ, Thomas EK, et al. Treatment of psychiatric illness by stereotactic cingulotomy. Biol Psychiatry. 1987;22(7):807-819.
  19. Rauch SL, Dougherty DD, Cosgrove GR, et al. Cerebral metabolic correlates as potential predictors of response to anterior cingulotomy for obsessive compulsive disorder. Biol Psychiatry. 2001;50(9):659-667.
  20. Center for Medicare and Medicaid Services (CMS). Stereotactic cingulotomy as a means of psychosurgery - not covered. Medicare Coverage Issues Manual. Medical Procedures. §35-84. CMS Pub. No. 6. Baltimore, MD: CMS; updated November 26, 2003. Available at: http://www.cms.hhs.gov/manuals/06_cim/. Accessed May 13, 2004.
  21. Temel Y, Visser-Vandewalle V. Surgery in Tourette syndrome. Mov Disord. 2004;19(1):3-14.
  22. Richter EO, Davis KD, Hamani C, et al. Cingulotomy for psychiatric disease: Microelectrode guidance, a callosal reference system for documenting lesion location, and clinical results. Neurosurgery. 2004;54(3):622-628; discussion 628-630.
  23. Yen CP, Kung SS, Su YF, et al. Stereotactic bilateral anterior cingulotomy for intractable pain. J Clin Neurosci. 2005;12(8):886-890.
  24. Jung HH, Kim CH, Chang JH, et al. Bilateral anterior cingulotomy for refractory obsessive-compulsive disorder: Long-term follow-up results. Stereotact Funct Neurosurg. 2006;84(4):184-189.
  25. National Institute for Health and Clinical Excellence (NICE). Obsessive-compulsive
    disorder: Core interventions in the treatment of obsessive-compulsive disorder
    and body dysmorphic disorder. Clinical Practice Guideline No. 31. London, UK: NICE; 2006.
  26. Steele JD, Christmas D, Eljamel MS, Matthews K. Anterior cingulotomy for major depression: Clinical outcome and relationship to lesion characteristics. Biol Psychiatry. 2008;63(7):670-677.
  27. Yen CP, Kuan CY, Sheehan J, et al. Impact of bilateral anterior cingulotomy on neurocognitive function in patients with intractable pain. J Clin Neurosci. 2009;16(2):214-219.
  28. Brotis AG, Kapsalaki EZ, Paterakis K, et al. Historic evolution of open cingulectomy and stereotactic cingulotomy in the management of medically intractable psychiatric disorders, pain and drug addiction. Stereotact Funct Neurosurg. 2009;87(5):271-291.
  29. Kim JP, Chang WS, Park YS, Chang JW. Impact of ventralis caudalis deep brain stimulation combined with stereotactic bilateral cingulotomy for treatment of post-stroke pain. Stereotact Funct Neurosurg. 2012;90(1):9-15.
  30. Jimenez F, Soto JE, Velasco F, et al. Bilateral cingulotomy and anterior capsulotomy applied to patients with aggressiveness. Stereotact Funct Neurosurg. 2012;90(3):151-160.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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