Page 1 of 5 ACTION: New Policy Effective Date: 03/15/2012 Revising Policy Number Review Dates: 10/22/07, 09/08/08, 05/24/11, Superseding Policy Number 05/29/12, 09/05/14, 09/01/17 Archiving Retiring Policy Number Johns Hopkins HealthCare LLC (JHHC) provides a full spectrum of health care products and services for Employer Health Programs, Priority Partners, Advantage MD, and US Family Health Plan. Each line of business possesses its own unique contract and guidelines which, for benefit and payment purposes, should be consulted to know what benefits are available for reimbursement. Specific contract benefits, guidelines or policies supersede the information outlined in this policy. ACTIVE AND ARCHIVED This document has been archived as of 09/05/2014 and is no longer scheduled for review for either one or more of the following reasons: 1. This document is either primarily administrative in nature AND/OR 2. It addresses operational issues only AND/OR 3. It is mandated by statute or regulation AND/OR 4. It is unlikely that further published literature would change the determination POLICY: ARCHIVED POLICIES REMAIN ACTIVE FOR THE PURPOSE OF MEDICAL NECESSITY DETERMINATION For US Family Health Plan see TRICARE Policy Manual 6010.57-M, February 1, 2008, Musculoskeletal System: Chapter 4, Section 6.1 and Nervous System: Chapter 4, Section 20.1. Thermal Intradiscal Procedures (TIPs) (CPT procedure codes 22526, 22527, 62287, and Healthcare Common Procedure Coding System (HCPCS) code S2348) are unproven. For Advantage MD, see Medicare Coverage Database: Local Coverage Determinations (LCDs) do not exist at this time. (Accessed June 2017) National Coverage Determination (NCD) for Thermal Intradiscal Procedures (TIPs) (150.11) I. When benefits are provided under the member s contract, JHHC considers open or percutaneous lumbar discectomies medically necessary. II. Unless specific benefits are provided under the member s contract, JHHC considers the following percutaneous techniques with or without endoscopic guidance for decompression of the cervical, lumbar
Page 2 of 5 or thoracic discs including but not limited to Laser discectomy, disc nucleoplasty experimental and investigational for all other indications, as they do not meet Technology Evaluation Criteria (TEC) #2-5. BACKGROUND: A variety of minimally invasive techniques have been investigated over the years as a treatment of back pain related to disc disease. Techniques can be broadly described as those techniques that are designed to remove or ablate disc material and thus decompress the disc (i.e., percutaneous lumbar discectomy, laser discectomy, and disc decompression using radiofrequency energy, referred to as a DISC nucleoplasty ). CODING INFORMATION: CPT Copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Note: The following CPT/HCPCS codes are included below for informational purposes. Inclusion or exclusion of a CPT/HCPCS code(s) below does not signify or imply member coverage or provider reimbursement. The member's specific benefit plan determines coverage and referral requirements. All inpatient admissions require pre-authorization. PRE-AUTHORIZATION REQUIRED Compliance with the provision in this policy may be monitored and addressed through post-payment data analysis and/or medical review audits Employer Health Programs (EHP) **See Specific Summary Plan Description (SPD) Priority Partners (PPMCO) refer to COMAR guidelines and PPMCO SPD then apply policy criteria US Family Health Plan (USFHP), TRICARE Medical Policy supersedes JHHC Medical Policy. If there is no Policy in TRICARE, apply the Medical Policy Criteria Advantage MD, LCD and NCD Medical Policy supersedes JHHC Medical Policy. If there is no LCD or NCD, apply the Medical Policy Criteria CPT 62287 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
Page 3 of 5 NOT COVERED CPT 22526 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level 22527 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure) HCPCS CODE S2348 procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar ICD10 ARE FOR INFORMATIONAL PURPOSES ONLY ICD10 M43.00- M43.9 Other deforming dorsopathies M51.06 - M51.07 Intervertebral disc disorder with myelopathy, lumbar/lumbosacral region M51.26- M51.27 Other intervertebral disc displacement, lumbar/lumbosacral regions REVENUE 0360 Operating Room Services-General; Hospital; outpatient 0450 Emergency Room-General;Hospital; outpatient 0490 Ambulatory Surgical Care-General;Hospital; outpatient REFERENCE STATEMENT: Analyses of the scientific and clinical references cited below were conducted and utilized by the Johns Hopkins HealthCare LLC (JHHC) Medical Policy Team during the development and implementation of this medical policy. Per NCQA standards, the Medical Policy Team will continue to monitor and review any newly published clinical evidence and adjust the references below accordingly if deemed necessary. REFERENCES: Aetna. (2016). Clinical Policy Bulletin: Back Pain Invasive Procedures. Medical 0016. Retrieved: http://www.aetna.com
Page 4 of 5 BCBS. (2016) Corporate Medical Policy. Automated Percutaneous and Endoscopic Discectomy. Retrieved: https://www.bcbsnc.com Brouwer, PA, Peul, WC, et al. (2009). Effectiveness of Percutaneous Laser Disc Versus Conventional Open Discectomy in The Treatment of Lumbar Disc Herniation: Design of a Prospective Randomized Controlled Trial. BioMed Central Musculoskeletal Disorders, Vol. 10:49. Chou, R. (2016). Subacute and Chronic Low Back Pain: Surgical Treatment. UpToDate. Retrieved: http://www.uptodate.com CIGNA. (2015). Medical Coverage Policy: Minimally Invasive Treatment of Back and Neck Pain. Medical 0139. Retrieved: https://www.supercoder.com Food and Drug Administration (FDA). (2008). 510(k) Summary: Arthroscope Accessory, Nucleotome Probe Set, Medical Device, April 8, 2004, and K082194, Percutaneous Discectomy System. Retrieved: http://www.accessdata.fda.gov Food and Drug Administration (FDA). (2003). 510(k) Summary: Stryker Dekompressor TM Percutaneous Discectomy Probe, Medical Device, Class II. Retrieved: http://www.accessdata.fda.gov Hayes, Inc. (2016). Health Technology Brief: Percutaneous Disc for Cervical Disc Herniation. Retrieved: https://www.hayesinc.com/ Hayes, Inc. (2011). Health Technology Brief: DISC Nucleoplasty (ArthroCare Perc TM D Spine Wand TM) for Percutaneous Disc. Retrieved: https://www.hayesinc.com/ Hayes, Inc. (2008). Health Technology Brief: Laser Discectomy. Retrieved: https://www.hayesinc.com/ InterQual Procedures Criteria 2013.2, Discectomy, Lumbar, InterQual View (Version 12.0 368), McKesson Health Solutions LLC. Retrieved from: http://vmiqview/rm/iqm/html/index.html. Lew, SM, Mehalic, TF, Fagone, KL. (2001). Transforaminal Percutaneous Endoscopic Discectomy in the Treatment of Far-Lateral and Foraminal Lumbar Disc Herniations. Journal of Neurosurgery, Volume 94, (2), p. 216-220. Regence BlueCross BlueShield. (2017). Medical Policy: Surgery Section, of Intervertebral Discs using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty). Medical Policy Number 131. Retrieved: http://blue.regence.com
Page 5 of 5 TRICARE. (2013). Policy Manual 6010.57-M, Surgery, Chapter 4, Section 20.1, Nervous System, C-87. Retrieved: http://manuals.tricare.osd.mil/ United Healthcare. (2017) Medical Coverage Policy: Discogenic Pain Treatment. Medical 2017T0105Q. Retrieved: https://www.unitedhealthcareonline.com