Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A57839 (Billing and Coding: Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A57839: Billing and Coding: Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor (Billing and Coding, effective 2025-02-21)
- Covered ICD-10-CM codes
- 2
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 1
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| G25.0 | — |
| G25.2 | — |
Procedure codes: 61715.
Coverage indications, limitations and medical necessity
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
History/Background and/or General Information
Historically, ultrasound has largely been performed as an extracranial diagnostic tool. However, more recently, intracranial therapeutic uses have been explored. One such use has been in the treatment of essential tremor (ET) that is refractory to more traditional treatment (e.g. medical therapy, deep brain stimulation [DBS]) through the use of focused ultrasound techniques. Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) is a non-invasive thermal ablation treatment that delivers a spherical array of converging beams using a cranial ultrasound unit that targets specific areas in the brain and heats and ablates the areas that are felt to be responsible for the ET. 1
C overed Indications
MRgFUS unilateral thalamotomy is considered medically reasonable and necessary in patients with all five of the following criteria:
• Presence of medication refractory ET 2,3 defined as refractory to at least two trials of medical therapy, including at least one first-line agent (i.e. propanalol or primidone); 2 and
• Presence of a moderate to severe postural or intention tremor (defined by a score greater than or equal to 2 on the clinical rating score for tremor [CRST] 2 or another nationally accepted clinical measure of tremor severity) of the dominant hand; and
• The tremor is disabling (defined by a score of greater than or equal to 2 on any of the eight items in the disability subsection of the CRST 2 or another nationally accepted clinical measure of tremor severity); and
• The beneficiary is not a candidate for deep brain stimulation (DBS) (e.g., advanced age, anticoagulant therapy, surgical comorbidities, or has failed DBS, but has no retained cranial implants); and
• The beneficiary is 22 years of age or older 3
Limitations
The following are considered not medically reasonable and necessary:
• Treatment of head or voice tremor
• Bilateral thalamotomy
• Treatment of beneficiaries who have an advanced neurodegenerative condition 2
• Treatment of beneficiaries with unstable cardiac disease 2
• Treatment of beneficiaries suffering from depression sufficiently severe to compromise their ability to provide informed consent and limit likely clinical benefit of the treatment
• Treatment of beneficiaries with severe cognitive impairment (defined by a score of less than 24 on the Mini–Mental State Examination) 2
• A skull density ratio (SDR) (the ratio of cortical to cancellous bone) less than 0.40 2
• Treatment when contraindications to MRI are present (e.g. metallic foreign body in eye, pacemaker etc.)
Provider Qualifications
• Consistent with the American Society for Stereotactic and Functional Neurosurgery (ASSFN) guidelines, physicians who perform MRgFUS must possess expertise and experience in functional and stereotactic neurosurgery. Additionally, physicians who perform these services should have underdone specialized training in MRgFUS. 2
Notice : Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.
Summary of evidence (opening)
Focused Ultrasound Thalamotomy Location Determines Clinical Benefits in Patients with Essential Tremor
Magnetic resonance guided focused ultrasound (MRgFUS) thalamotomy is a novel and minimally invasive ablative treatment for essential tremor. This study examined relationships in patients with essential tremor undergoing MRgFUS. Boutet et al. studied 66 patients with essential tremor who underwent MRgFUS between 2012 and 2017. The study assessed the Clinical Rating Scale for Tremor (CRST) scores at 3 months after the procedure and tracked the adverse effects (sensory, motor, speech, gait, and dysmetria) 1 day (acute) and 3 months after the procedure. The results indicated the area of optimal tremor response at 3 months after the procedure was identified at the posterior portion of the ventral intermediate nucleus. Lesions extending beyond the posterior region of the ventral intermediate nucleus and lateral to the lateral thalamic border were associated with increased risk of acute adverse sensory and motor effects, respectively. 1
Magnetic Resonance-Guided Focused Ultrasound Neurosurgery for Essential Tremor: A Health Technology Assessment
In this study, a systematic review of the clinical literature published up to April 11, 2017, that examined MRgFUS neurosurgery alone or compared with other interventions for the treatment of moderate to severe, medication-refractory essential tremor was performed. The review assessed the risk of bias of each study and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. The inclusion criteria was that the articles were all full text publications in English, all published prior to April 11, 2017, were randomized controlled trials, systematic reviews, and nonrandomized studies of MRgFUS neurosurgery alone or MRgFUS neurosurgery compared with one or more of the following: radiofrequency thalamotomy, deep brain stimulation (unilateral or bilateral), gamma Knife thalamotomy, or control intervention.
The contractor cites 17 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2020-07-12
- Current revision effective
- 2020-07-12
- MCD version
- 7
The contractor lists one National Coverage Determination as related: NCD 160.24 Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.
Other related documents: A58049 (Response to Comments).
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Novitas Solutions, Inc. hub lists every other active policy from the same contractor.
The same policy title at other contractors
Contractors often adopt each other's policies and then revise them separately, so the criteria and the diagnosis lists drift apart. The topic comparison lines up every version.
Frequently asked questions
What does LCD L38495 cover?
Historically, ultrasound has largely been performed as an extracranial diagnostic tool. However, more recently, intracranial therapeutic uses have been explored. One such use has been in the treatment of essential tremor (ET) that is refractory to more traditional treatment (e.g. medical therapy, deep brain stimulation [DBS]) through the use of focused ultrasound techniques. Magnetic-Resonance-Guided Focused… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L38495 apply to?
Novitas Solutions, Inc. applies it to Medicare claims in AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L38495?
The companion billing and coding article A57839 lists 2 ICD-10-CM codes in 1 group that support medical necessity; the first 2 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L38495?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.