Minimally invasive and laser spine procedures

Transcription

1 Minimally invasive and laser spine procedures These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage. Administrative Process Prior authorization is required when requested for the following non-covered conditions: 1. Laser facet ablation / denervation /rhizotomy (64633, 64634, 64635, 64636) 2. Epidurolysis / percutaneous adhesiolysis (when coded with 64640) 3. Minimally invasive lumbar decompression MILD procedure. (0274T, 0275T) Prior authorization is not required for microdisectomy, also known as percutaneous manual nucleotomy. Prior authorization is not applicable for minimally invasive spine procedures and laser spine procedures because these services are considered investigational/experimental. The provider and facility will be liable for payment unless: 1. The provider notifies the member that a specific service has been determined by HealthPartners to be investigational/experimental; and 2. The member signs a waiver agreeing to pay for the specific non-covered service being rendered; and 3. The claim has been billed with a GA modifier indicating such. If the member has signed a waiver agreeing to pay for the specific service then the member will be liable for payment. Coverage Microdiscectomy, also known as percutaneous manual nucleotomy, is generally covered subject to the indications listed below and per your plan documents. Minimally invasive back procedures are considered investigational/experimental and therefore not covered. Procedures that are covered Microdiscectomy, also known as percutaneous manual nucleotomy Procedures that are not covered The following procedures are considered investigational and not covered because the reliable evidence does not permit conclusions to concerning safety, effectiveness, or effect on health outcomes. 1. Laser spine procedures, including but not limited to: A. Laser discectomy, also known as laser-assisted discectomy, laser disc decompression or laser-assisted disc decompression (LADD) (62287) B. Percutaneous laser discectomy (62287) C. Laparoscopic laser discectomy D. Endoscopic laser foraminoplasty E. Endoscopic laser foraminotomy F. Endoscopic laser laminotomy G. Laser laminectomy H. Laser facet ablation / denervation /rhizotomy (64633, 64634, 64635, 64636) Clinical studies have not shown a clinically significant benefit of use of laser over any other method of tissue resection in spinal surgery. No additional benefit will be provided for the use of a laser in spinal surgery. 2. Percutaneous and endoscopic laminectomy and disc decompression procedures of the cervical, thoracic, or lumbar spine including but not limited to: A. Percutaneous endoscopic discectomy with or without laser (PELD) (also known as arthroscopic microdiscectomy or Yeung Endoscopic Spinal Surgery System (Y.E. S.S.)) B. APLD (Automated percutaneous lumbar discectomy) (62287) C. Endoscopic procedures using the DiscFX System D. Minimally invasive lumbar decompression MILD procedure. (0274T, 0275T) 3. Thermal intradiscal procedures (TIPs) including but not limited to: A. Intradiscal electrothermal therapy ( IDET) / Intradiscal electrothermal annuloplasty (IEA)/ Intradiscal thermal annuloplasty (IDTA) (22526, 22527) Page 1 of 5

2 B. Nucleoplasty/decompression nucleoplasty/percutaneous (or plasma) disc decompression (PDD) (e.g., SpineWand coblation therapy) C. Transdiscal biacuplasty/ Intradiscal biacuplasty (IDB)/cooled radiofrequency ablation (RFA) (22526, 22527) D. Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) (22526, 22527) Intradiscal steroid injection (0213T- 0218T) Devices for annulus repair (i.e. X-close) Epidurolysis / percutaneous epidural adhesiolysis (62263, 62264, 64640) Endoscopic radiofrequency denervation/rhizotomy Definitions Discectomy is the incision and removal of part or the whole spinal disc. Foraminectomy and foraminotomy are performed to expand the openings (foramen) for the nerve roots to exit the spinal cord by removing some bone and other tissue. A foraminectomy or foraminotomy is often performed on an individual who has arthritis, a lateral disc herniation, or spinal stenosis. The term foraminectomy is used to refer to a procedure that removes a large amount of bone and tissue, and foraminotomy when a smaller amount is removed. Intradiscal steroid injection is sometimes performed at the same time as a discography is performed. Intradiscal thermal procedures are proposed to treat back pain arising from spinal disc abnormalities. The goal is to relieve pain arising from the disc and repair structural abnormalities. Heat is generated by the direct or indirect radiofrequency energy. Cooled radiofrequency ablation (RFA) / Transdiscal biacuplasty is similar to IDET but is performed via a bipolar method, producing a field between two introducer needles. Intradiscal biacuplasty is a minimally invasive transdiscal radiofrequency technique for treatment of back pain. Intradiscal biacuplasty uses two internally water-cooled radiofrequency probes to lesion nociceptors in the intervertebral disc. IDET (intradiscal electrothermal therapy (also known as intradiscal electrothermal annuloplasty (IDTA) or IEA) involves a heat probe being inserted into the spine (usually via an endoscope) at the point causing pain. The tissue is heated by the probe, which causes it to shrink and scar Percutaneous intardiscal radiofrequency thermocoagulation (PIRFT) applies radiofrequency energy directly to the center of the disc. Lumbar disc herniation is the most common cause of sciatic pain (nerve pain radiating down the leg). Lumbar disc herniation or radiculopathy is caused when the casing around the disc bursts and some of the gel like disc material seeps out, sometimes causing pain. In some instances it presses on the sciatic nerve, causing the nerve pain radiating down the leg. Microdiscectomy is a discectomy done with a very small incision, usually about 1 inch long using manual instruments and technique. Minimally invasive lumbar decompression (MILD) - An emerging minimally invasive surgery for lumbar spinal stenosis is known as MILD (minimally invasive lumbar decompression), a percutaneous decompression technique that increases the dimensions of the spinal canal, thereby achieving nerve decompression. The MILD procedure is an image-guided surgery the surgical site is not directly visualized but rather surgery is guided by fluoroscopy. Percutaneous refers to the insertion of a cannula, tube or endoscope through the skin. An endoscope is a highly flexible viewing instrument with capabilities of diagnostic (biopsy) or even therapeutic functions through special channels. It looks like a large flexible needle and makes a very small incision. Many percutaneous discectomy procedures are performed by inserting the different devices through an endoscope. Percutaneous intradiscal procedures are minimally invasive techniques providing percutaneous access to paingenerating discs. These procedures have been developed to treat discogenic LBP, including radiculopathy and sciatica by way of partial removal of the nucleus pulposus (gel like disc material) to reduce intradiscal pressure. Partial removal of the nucleus pulposus has been shown to decompress herniated discs, relieving pressure on nerve roots and, in some cases, offering relief from discogenic pain. Percutaneous intradiscal procedures may surgically extract disc material, destroy disc material or alter the disc through the application of heat. APLD (Automated percutaneous lumbar discectomy) involves a probe inserted through a cannula and used both as a cutting instrument and for aspiration of disc material. Disc nucleoplasty (also known as percutaneous radiofrequency thermomodulation, percutaneous Page 2 of 5

3 plasma discectomy or plasma disc decompression [PDD]) is a minimally invasive procedure to treat individuals with symptomatic low back and leg pain caused by herniated discs. The procedure utilizes a device called the ArthroCare Perc-D SpineWand, which includes the Perc DLR, the Perc DLG and the Perc DC. The SpineWand is designed to relieve pressure on spinal nerves adjacent to the disc by removing disc material. This procedure relies on a patented technology referred to as Coblation, in which the SpineWand applies a high-frequency electric current directly to the saline medium inside the disc, generating a tightly focused field of highly energized molecules around the tip of the wand. Laser Discectomy is a percutaneous procedure which uses a laser device to shrink the enlarged disc that is causing the low back pain. There are several FDA approved laser discectomy devices, including LASE (laser assisted spinal endoscopy), LADD (laser assisted disc decompression), and others. Percutaneous lumbar discectomy (PLD) is a term for two minimally invasive surgical techniques / intradiscal procedures for treating contained herniated discs. Percutaneous manual nucleotomy refers to the technique involving the use of specialized forceps and curettes to remove the disc through a cannula. Codes If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive. CPT codes that are covered services: Lumbar microdiscectomy/percutaneous manual nucleotomy Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar CPT codes that are NOT covered services: Laser discectomy, also known as laser-assisted discectomy, laser disc decompression or laser-assisted disc decompression Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure) Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar C2614 Probe, percutaneous lumbar discectomy Unlisted procedure, spine Unlisted procedure, nervous system Intradiscal steroid injection 0213T Injection(s), diagnostic or therapeutic agent, paravetebral facet (zygapophyseal) joint (or nerves 0218T innervating that joint) with ultrasound guidance, various levels, etc. CPT codes that require prior authorization: Laser facet ablation / denervation /rhizotomy - These codes also refer to the policy titled: Radiofrequency ablative denervation (RFA) procedures for chronic facet-mediated neck & back pain Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy Page 3 of 5

4 or CT); lumbar or sacral, single facet joint Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) Epidurolysis / percutaneous adhesiolysis Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day Destruction by neurolytic agent; other peripheral nerve or branch Percutaneous laminotomy/laminectomy, MILD procedure minimally invasive lumbar decompression 0274T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic 0275T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Products This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at or References Chou, Roger, John D. Loeser, Douglas K. Owens, Richard W. Rosenquist, Steven J. Atlas, Jamie Baisden, Eugene J. Carragee, Martin Grabois, Donald R. Murphy, Daniel K. Resnick, Steven P. Stanos, William O. Shaffer, and Eric M. Wall.(2009) "Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain."Spine 34.10: Chou R, Atlas SJ, Stanos SP, Rosenquist RW. (2009). Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine. May 1;34(10): Chou, R. Subacute and chronic low back pain: nonsurgical interventional treatment. In: UpToDate, Atlas, SJ (Ed), UpToDate, Waltham, MA. (Accessed on June, 2017.) Chou, R. Subacute and chronic low back pain: surgical treatment. In: UpToDate, Atlas, SJ (Ed), UpToDate, Waltham, MA. (Accessed on June, 2017.) *ECRI Institute. (2011). Laser Discectomy for the Treatment of Herniated Lumbar Discs. Plymouth Meeting, PA: ECRI Institute. ECRI Institute. (2012). Lateral and Axial Lumbar Interbody Fusion Systems for Minimally Invasive Spinal Fusion Surgery. Plymouth Meeting, PA: ECRI Institute. ECRI Institute. (2011). Minimally Invasive Lumbar Decompression for Treating Degenerative Lumbar Disease. Plymouth Meeting, PA: ECRI Institute. ECRI Institute (2016). Percutaneous Laser Disc Decompresssion for Treating Herniated Lumbar Discs. Plymouth Meeting (PA): ECRI Institute. ECRI Institute. (2012). Racz Procedure for Treating Chronic Low-back Pain. Plymouth Meeting, PA: ECRI Institute. ECRI Institute. (2012). Radiofrequency Denervation for Treating Chronic Low-Back Pain. Plymouth Meeting, PA: ECRI Institute *ECRI Institute. Surgical Devices for Repairing Annulus Fibrosus after Discectomy. Plymouth Meeting (PA): ECRI Institute; 2015 Sep 15. (Custom Rapid Review). Finch, P. M., Price, L. M., & Drummond, P. D. (2005). Radiofrequency heating of painful annular disruptions: one-year outcomes. Clinical Spine Surgery, 18(1), Gibson JNA, Grant IC, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane DatabaseSyst Rev Apr 18;(2):CD Page 4 of 5

5 14. Hayes, Inc. Hayes Health Technology Brief. Endoscopic Epidural Adhesiolysis for Chronic Back Pain. Lansdale, PA: Hayes, Inc.; December, Hayes, Inc. Hayes Health Technology Brief. Endoscopic Laser-Assisted Discectomy for Cervical Disc Herniation. Lansdale, PA: Hayes, Inc.; February, Reviewed March, 2011; Archived February, Hayes, Inc. Hayes Health Technology Brief. Athroscopic Microdiscectomy for Lumbar Disc Herniation. Lansdale, PA: Hayes, Inc.; December, 2011, Reviewed June Archived, January, Hayes, Inc. Hayes Health Technology Brief. Cooled Radiofrequency Denervation of the Sacroiliac Joint for Treatment of Chronic Low Back Pain. Lansdale, PA: Hayes, Inc.; August 2011, reviewed Aug 2012; archived Hayes, Inc. Hayes Health Technology Brief. DISC Nucleoplasty ArthroCare Perc -D SpineWand ) for Percutaneous Disc Decompression. Lansdale, PA: Hayes, Inc.; December 2007, Archived January Hayes, Inc. Hayes Health Technology Brief. 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Approved Medical Director Committee 4/8/05; Revised 10/31/07, 7/14/10 with changes effective 11/1/10, 3/15/13, 5/23/13, 7/27/17, 11/15/17; Annual Review 7/1/06; 10/31/07, 8/1/08, 9/9/09, 5/14/10, 7/14/10, 4/2011, 4/2012, 3/15/13, 5/2013, 3/2014, 3/2015, 3/2016, 3/2017, 3/2018 Page 5 of 5