How Does Medicare Cover Essential Tremor?

By Danielle Kunkle Roberts,
Co-Founder of Boomer Benefits

Danielle Kunkle Roberts, Boomer BenefitsEssential Tremor (ET) is a neurological disorder that causes involuntary shaking and trembling. It affects approximately 10 million people in America, according to the International Essential Tremor Foundation, which makes ET the most common neurological disorder.

While not dangerous, the condition can make simple tasks such as tying your shoes or drinking a glass of water more difficult. ET can also get worse over time.

Because ET is more common for people in later adulthood, it’s good to know how Medicare will cover treatment of this disorder.

Medicare Part A Hospital Benefits

Original Medicare is made up of Part A hospital benefits and Part B outpatient benefits. 

Part A covers inpatient hospital stays, skilled nursing facility care, and hospice care. This is the part that would pay most of the expenses related to a hospital stay for deep brain simulation (DBS), which is a common surgery that provides relief from tremors and stiffness.

Medicare Part B Hospital Benefits

Medicare Part B covers outpatient care. This includes doctor visits, preventive care, lab-work, diagnostic testing, emergency care, outpatient surgeries, physical therapy, durable medical equipment and much more.

Part B will pay for your patient visits to your specialist, the necessary neurological exams and lab-work and any outpatient procedures used to control ET symptoms.

One outpatient procedure to treat ET is focused ultrasound treatment. This minimally invasive treatment was approved by the FDA in 2016. It is the first brain disorder treatment to be allowed reimbursement by Medicare Part B. The procedure destroys a small amount of brain tissue that contains nerve cells which are responsible for the tremors.

Earlier this summer Medicare announced benefit coverage for patients in 16 states. Additional states were added this past fall. There are numerous medical centers that now treat patients with Essential Tremor using MR-guided focused ultrasound. A Medicare physician must document why the procedure is reasonable and necessary.

Medicare Part D Drug Benefits

Outpatient medications to help treat your ET symptoms will fall under Part D. Medicare Part D is optional coverage  beneficiaries can purchase to reduce the cost of their prescriptions.

These plans are sold by private insurance companies and each plan has its own premiums, copays, coinsurance, pharmacy network, and drug formulary. Beneficiaries can use Medicare’s Plan Finder Tool to search for the right plan.

Your Medicare Cost-Sharing

As with all insurance coverage, Medicare covers a share and the member also pays a share of their coverage. This is called your cost-sharing and it usually comes in the form of deductibles, copays, and coinsurance.

Part A has a $1364 deductible in 2019, and Part B has a smaller $185 annual deductible. Medicare Part B covers 80% of your outpatient procedures. You are responsible for paying the other 20%.

Fortunately, you can supplement your coverage with either a Medicare supplement policy or a Medicare Advantage plan. Both types of coverage will help to limit your out-of-pocket expenses on the gaps in Medicare.

Beneficiaries can call 1-800-MEDICARE or consult a Medicare insurance broker for guidance in choosing a plan that fits their needs and benefits.

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Danielle K. Roberts is a Medicare insurance expert and co-founder at Boomer Benefits, a licensed agency that helps beneficiaries with their supplemental coverage options.

Wrapping Your Mind Around Head Tremor

(This is an article from a past issue of Tremor Talk magazine. It’s just a sampling of the stories we include in each issue. Annual donors to the IETF receive Tremor Talk magazine in the mail three times per year.)

By Arif Dalvi, MD, MBA
Director of the Comprehensive Movement Disorders Program
Palm Beach Neuroscience Institute 

Dr. Arif DalviThe term tremor refers to an involuntary shaking of any part of the body. While tremor in the hands is most common, head tremor can also occur. In patients with essential tremor, head tremor can be an isolated symptom or may occur in combination with hand tremor. Essential tremor is by far the most common cause of head tremor. Another cause is cervical dystonia, also known as spasmodic torticollis. Head tremor may also occur in patients with Parkinson’s disease. Stroke, head injury, and multiple sclerosis are other causes of tremor but are less likely to cause head tremor.

Hyperexcitability and rhythmic activity in the circuits of the brain are believed to be the underlying mechanism for tremor. One such circuit includes three areas deep in the brain called the red nucleus, the inferior olivary nucleus (ION), and the dentate nucleus. This circuit is responsible for fine-tuning voluntary movements. Proper function prevents any undershoot or overshoot of movements. An abnormal response in this circuit, especially within the ION, can lead to tremor.

Approximately 95 percent of patients with essential tremor present with hand tremor. However, about 35 percent of patients have head tremor either by itself or in conjunction with hand tremor. Some patients also have voice tremor. Hand tremor occurs mostly with posture, such as when holding an object away from the body and against gravity. This contrasts with hand tremor in Parkinson’s disease that occurs when the hands are at rest. Muscle rigidity, slowness of movement, change in posture and gait also occur with Parkinson’s disease but are uncommon with essential tremor. A lip or chin tremor may also be seen in patients with Parkinson’s disease.

Cervical dystonia can be another cause of head tremor. Dystonia refers to a state of abnormal muscle tone leading to painful muscle spasms and abnormal posturing of a part of the body. When the muscle spasms and abnormal posture affect the neck it is referred to as cervical dystonia. Sustained abnormal posturing of the head is a hallmark of cervical dystonia. An enlargement of the neck muscles may be observed in cervical dystonia but is unusual in essential tremor.

Other features include an asymmetric elevation of the shoulders, excessive eye blinking or blepharospasm, and spasms of the facial muscles. Like ET, cervical dystonia can spread to one or the other arm, in long-standing cases. However, unlike essential tremor the head tremor from cervical dystonia may be associated with neck pain due to dystonic spasms.

Patients with cervical dystonia may employ sensory tricks to reduce the severity of the tremor. Touching the cheek or chin (a geste antagoniste) is a commonly employed sensory trick. Head tremor with cervical dystonia has a directional component and is usually worse when looking in one direction and reduced when looking in the opposite direction. It may be possible when examining the individual to find a head position where the tremor almost disappears. This position is referred to as a “null point”.

The diagnosis of tremor remains a clinical diagnosis. An MRI or CT scan of the brain is usually ordered to rule out structural lesions such as stroke, multiple sclerosis or a midbrain tumor. In patients where there is a question of whether the problem is essential tremor or parkinsonism, a DaTscan may be ordered. This scan is targeted towards the dopamine transporter (DaT) in the brain which is deficient in parkinsonism but normal in essential tremor. Blood tests to rule out hyperthyroidism and, in younger patients, screening tests for Wilson’s disease may also be considered.

The treatment of tremor is guided by the underlying cause. Propranolol and primidone are the mainstay of treatment for essential tremor. Other medication options that are helpful include gabapentin and topiramate. Cervical dystonia may respond to treatment with benzodiazepines. Clonazepam, which is a long-acting benzodiazepine, may be preferred in comparison to shorter acting drugs such as alprazolam or lorazepam. Baclofen can reduce dystonia by acting on GABAB receptors. Tizanidine is an alternative to baclofen. However, since tizanidine can cause liver damage (in rare cases), monitoring of liver enzymes for the first six months is recommended.

Botulinum toxins can play a role in the treatment of head tremor, particularly in dystonic head tremor. Botulinum toxins block the release of neurotransmitters. This results in decreased transmission of the signal from nerve ending to the muscle, thus reducing the tremor. Repeat injections are required every three to four months.

Deep brain stimulation (DBS) surgery was approved by the FDA in 1997 for the treatment of tremor. However, the target in the brain varies based on the condition being treated. DBS surgery carries an approximately two percent risk of bleeding in the brain, hence it is only offered to patients with advanced tremor that is disabling and not controlled by medications. Head tremor can be more difficult to control than hand tremor and may require DBS surgery to be done on both sides of the brain.

Non-pharmacological methods to reduce head tremor rarely provide sustained benefit. Physical therapy is generally not useful, however, relaxation techniques can help reduce tremor as anxiety is often an exacerbating factor. There is no specific diet that is helpful but reducing caffeine intake can help reduce tremor.

Not every person with ET will be affected by head tremor. But if you are, it is important to talk to your physician so you understand what it is and what treatment options are best for you.