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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-61000-32

Original Effective Date: 05/15/04

Reviewed: 06/26/14

Revised: 01/01/17

Subject: Automated Percutaneous Discectomy, Laser Discectomy, Endoscopic Discectomy, or DISC Nucleoplasty™ as Techniques of Intervertebral Disc Decompression

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Back pain related to herniated discs is an extremely common condition and a frequent cause of chronic disability. Although many cases of acute low back pain will resolve with conservative care, a surgical decompression is often considered when the pain is unimproved and is clearly neuropathic in origin, resulting from irritation of the nerve roots. Open surgical treatment typically consists of some sort of discectomy, where the extruding material is excised.

A variety of minimally invasive techniques have been investigated over the years as a treatment of low back pain related to disc disease. Techniques can be divided into techniques that are designed to remove or ablate disc material and thus decompress the disc include chemonucleolysis, automated percutaneous lumbar discectomy, laser discectomy, and most recently disc decompression using radiofrequency energy, referred to as a DISC nucleoplasty™. Automated percutaneous discectomy, laser discectomy and DISC nucleoplasty™ are the subjects of this policy.

Percutaneous discectomy for disc decompression is accomplished by the physical removal of disc material rather than its ablation. Originally percutaneous discectomy was performed manually, using cutting forceps to remove nuclear material from within the disc annulus. This technique has been replaced with automated devices that involve placement of a probe within the intervertebral disc and aspiration of disc material using a suction cutting device. The Stryker DeKompressor Percutaneous Discectomy Probe (Stryker) and the Nucleotome (Clarus Medical) are examples of percutaneous discectomy devices that received clearance from the U.S. Food and Drug Administration (FDA) through the 510(k) process. Both have the same labeled intended use “for use in aspiration of disc material during percutaneous discectomies in the lumbar, thoracic and cervical regions of the spine.

A variety of different lasers have been investigated for laser discectomy, including YAG, KTP, holmium, argon, and carbon dioxide lasers. Regardless of the type of laser, the procedure involves placement of the laser within the nucleus under fluoroscopic guidance and then activated. Due to differences in absorption, the energy requirements and the rate of application differ among the lasers. In addition, it is unknown how much disc material must be removed to achieve decompression. Protocols vary according to the length of treatment, but typically the laser is activated for brief periods only.

The DISC nucleoplasty™ procedure uses bipolar radiofrequency energy in a process referred to as coblation technology. The technique consists of small multiple electrodes that emit a fraction of the energy required by traditional radiofrequency energy systems. The result is that a portion of nucleus tissue is ablated not with heat, but with a low-temperature plasma field of ionized particles. These particles have sufficient energy to break organic molecular bonds within tissue, creating small channels in the disc. The proposed advantage of this coblation technology is that the procedure provides for a controlled and highly localized ablation, resulting in minimal therapy damage to surrounding tissue.

This policy also addresses endoscopic discectomy, in which the disc decompression is accomplished by the physical removal of disc material rather than its ablation. Traditionally, discectomy is performed manually through an open incision, using cutting forceps to remove nuclear material from within the disc annulus. This technique has been modified by automated devices that involve placement of a probe within the intervertebral disc and aspiration of disc material using a suction cutting device. Endoscopic techniques may be intradiscal or may involve the extraction of non-contained and sequestered disc fragments from inside the spinal canal using an interlaminar or transforaminal approach. Following insertion of the endoscope, the decompression is performed under visual control.

POSITION STATEMENT:

Automated percutaneous discectomy, laser discectomy, endoscopic discectomy, DISC nucleoplasty™, and any other method of percutaneous disc decompression are considered experimental or investigational, as there is insufficient clinical evidence to support the use of percutaneous discectomy, laser discectomy and DISC nucleoplasty as techniques of disc decompression in patients with back pain related to disc herniation in the lumbar, thoracic or cervical spine. Published studies are inconsistent and do not demonstrate long-term improvement. The evidence is insufficient to permit conclusions on net health outcomes.

BILLING/CODING INFORMATION:

CPT Coding

62287

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 discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar. (Investigational)

0274T*

Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), single or multiple levels, unilateral or bilateral; cervical or thoracic. (Investigational)

0275T*

Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar. (Investigational)

*Note: Percutaneous discectomy is also a component of 0274T and 0275T.

HCPCS Coding:

S2348

Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single of multiple levels, lumbar (investigational)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determinations (NCD) were reviewed on the last guideline reviewed date: Laser Procedures (140.5); Thermal Intradiscal Procedures (TIPS) (150.11); and Percutaneous image-guided lumbar decompression for lumbar spinal stenosis (150.13), located at cms.gov.

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Non-covered Services (L29288) located at fcso.com.

DEFINITIONS:

Annulus: a ring of fibrous or fibrocartilaginous tissue (as of an intervertebral disk or surrounding an orifice of the heart).

Discectomy: surgical removal of an intervertebral disk.

Nucleus pulposus: an elastic pulpy mass lying in the center of each intervertebral fibrocartilage and regarded as a remnant of the notochord.

RELATED GUIDELINES:

Thermal Intradiscal Procedures (e.g., IDET, IDB, PIRFT), 02-61000-20

OTHER:

Other names used to report DISC nucleoplasty™:

Coblation, disc decompression
Disc nucleoplasty

REFERENCES:

  1. American Society of Interventional Pain Physicians (ASIPP) practice guidelines (2013). Accessed 04/23/14.
  2. American Pain Society clinical practice guidelines (2009). Accessed 04/23/14.
  3. Arts MP, Peul WC, Brand R, Koes BW, Thomeer RT. Cost-effectiveness of microendoscopic discectomy versus conventional open discectomy in the treatment of lumbar disc herniation: a prospective randomised controlled trial [ISRCTN51857546]. BMC Musculoskelet Disord. 2006 May 13; 7: 42.
  4. Azzazi A, AlMekawi S, Zein M. Lumbar disc nucleoplasty using coblation technology: clinical outcome. J Neurointerv Surg. 2011 Sep;3(3):288-92.
  5. Blue Cross Blue Shield Association. Medical Policy Reference Manual. 7.01.18 Automated Percutaneous and Endoscopic Discectomy. 04/11/13.
  6. Blue Cross Blue Shield Association. Medical Policy Reference Manual. 7.01.93. Decompression of the Intervertebral Disc Using Laser (Laser Discectomy) or Radiofrequency Energy (DISC Nucleoplasty™). 07/11/13.
  7. Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L; American Society of Interventional Pain Physicians. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007 Jan; 10(1): 7-111.
  8. Boswell MV, Trescot, AM, Datta S, Schultz DM, Hansen HC, et al. Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain. Pain Physician 2009; 12:699-802 – ISSN 1533-3159.
  9. Brouwer PA, Peul WC, Brand R, Arts MP, Koes BW, van den Berg AA, van Buchem MA. Effectiveness of percutaneous laser disc decompression versus conventional open discectomy in the treatment of lumbar disc herniation; design of a prospective randomized controlled trial. BMC Musculoskelet Disord. 2009 May 13;10:49.
  10. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination for Laser Procedures (140.5). 05/01/97.
  11. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination for Thermal Intradiscal Procedures (TIPS) (150.11). 01/09/09.
  12. Chen Y, Derby R, Lee SH. Percutaneous disc decompression in the management of chronic low back pain. Orthop Clin North Am. 2004 Jan; 35(1): 17-23.
  13. Chou R, Loeser JD, Owens DK et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976) 2009; 34(10):1066-77.
  14. ClinicalTrials.gov, Study of Percutaneous Intradiscal Nucleoplasty Efficacy, sponsored by ArthroCare Corporation, accessed on 05/25/07.
  15. ClinicalTrials.gov, Surgical Treatment comparison for Recurrent Lumbar Disc Herniation, sponsored by St. John’s Health System & Zimmer. Accessed 05/17/12.
  16. ClinicalTrials.gov. Radiofrequency Nucleoplasty vs. Percutaneous Nucleotomy (Dekompressor vs. Decompression Catheter for the Treatment of Painful Contained Lumbar Disc Herniation. NCT00300898. Accessed 05/17/12.
  17. ClinicalTrials.gov. Safety and Effectiveness Study of the AO-1000 Device to Treat Contained Herniated Discs. NCT01339377. Accessed 05/17/12.
  18. Davis TT, Sra P, Fuller N, Bae H. Lumbar intervertebral thermal therapies. Orthop Clin North Am. 2003 Apr; 34(2): 255-62.
  19. ECRI Custom Hotline Response. Nucleoplasty (Coblation) for Lumbar Herniated Disc and Discogenic Pain. Plymouth Meeting, PA: ECRI. January 2006, updated 04/19/07.
  20. ECRI Windows on Medical Technology™. Automated Percutaneous Nucleotomy for Herniated Lumbar Discs. Plymouth Meeting, PA: ECRI. April 2005. Issue No. 124.
  21. ECRI Windows on Medical Technology™. Laser Discectomy for the Treatment of Herniated Lumbar Discs. Plymouth Meeting, PA: ECRI. December 2004. Issue No. 119.
  22. ECRI. Custom Hotline Response. Percutaneous Cervical Discectomy for Disc Herniation. Plymouth Meeting, PA: ECRI. 12/31/07.
  23. Erginousakis D, Filippiadis DK, Malagari A, Kostakos A, Brountzos E, Kelekis NL, Kelekis A. Radiology. Comparative prospective randomized study comparing conservative treatment and percutaneous disk decompression for treatment of intervertebral disk herniation. 2011 Aug;260(2):487-93.
  24. First Coast Service Options (FCSO) Local Coverage Determination for Non-covered Services (L29288) (01/29/13).
  25. Gerges FJ, Lipsitz SR, Nedeljkovic SS. A systematic review on the effectiveness of the Nucleoplasty procedure for discogenic pain. Pain Physician. 2010 Mar-Apr;13(2):117-32.
  26. Gibson JNA, Waddell G. Surgery for degenerative lumbar spondylosis. The Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD001352. DOI: 10.1002/14651858.CD001352.pub3.
  27. Gibson JNA, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD001350. DOI: 10.1002/14651858.CD001350.pub4.
  28. Hayes, Inc. HAYES Medical Technology Directory™. Automated Percutaneous Lumbar Discectomy. Lansdale, PA: Hayes, Inc.; 05/12/06. Update performed 05/20/08.
  29. Hayes, Inc. HAYES Medical Technology Directory™. Laser Discectomy. Lansdale, PA: Hayes, Inc.; 06/10/02. Update performed 04/30/06.
  30. Hayes, Inc. Health Technology Brief. Disc Nucleoplasty┬« (Perc™-D┬« SpineWand™) (ArthroCare Corp.) for Percutaneous Disc Decompression Lansdale, PA: Hayes, Inc. 12/30/07.
  31. Hegmann KT, editor(s). Cervical and thoracic spine disorders. Occupational medicine practice guidelines. Evaluation and management of common health problems and functional recovery in workers. 3rd ed. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2011. p. 1-332.
  32. Hegmann KT, editor(s). Low Back Disorders. Occupational medicine practice guidelines. Evaluation and management of common health problems and functional recovery in workers. 3rd ed. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2011. p. 333-796.
  33. Hirsch JA, Singh V, Falco FJ, Benyamin RM, Manchikanti L. Automated percutaneous lumbar discectomy for the contained herniated lumbar disc: a systematic assessment of evidence. Pain Physician. 2009 May-Jun;12(3):601-20.
  34. Manchikanti L, Boswell MV, Singh V, Benyamin RM, Fellows B, Abdi S, Buenaventura RM, Conn A, Datta S, Derby R, Falco FJ, Erhart S, Diwan S, Hayek SM, Helm S, Parr AT, Schultz DM, Smith HS, Wolfer LR, Hirsch JA. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician 2009 Jul-Aug;12(4):699-802 (updated 01/28/10).
  35. Manchikanti L, Derby R, Benyamin RM et al. A systematic review of mechanical lumbar disc decompression with nucleoplasty. Pain Physician 2009; 12(3):561-72.
  36. Manchikanti L, Falco FJ, Benyamin RM, Caraway DL, Deer TR, Singh V, Hameed H, Hirsch JA. An update of the systematic assessment of mechanical lumbar disc decompression with nucleoplasty. Pain Physician. 2013 Apr;16(2 Suppl):SE25-54.
  37. Manchikanti L, Singh V, Falco FJ, Calodney AK, Onyewu O, Helm S 2nd, Benyamin RM, Hirsch JA. An updated review of automated percutaneous mechanical lumbar discectomy for the contained herniated lumbar disc. Pain Physician. 2013 Apr;16(2 Suppl):SE151-84.
  38. National Guideline Clearinghouse. Comprehensive Evidence-based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain by the American Society of Interventional Pain Physicians (2009).
  39. National Guideline Clearinghouse. Low back disorders. 2004.
  40. National Guideline Clearinghouse. Low Back Disorder—Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers by the American College of Occupational and Environmental Medicine (2007).
  41. National Guideline Clearinghouse. Lower Back - Lumbar & Thoracic (Acute & Chronic) by the Work Loss Data Institute (WLDI) (2011).
  42. National Institute for Clinical Excellence (NICE) Interventional Procedure Guidance (IPG) 61. Percutaneous endoscopic laser thoracic discectomy. May 2004.
  43. National Institute for Clinical Excellence (NICE) Interventional Procedure Guidance (IPG) 141. Automated percutaneous mechanical lumbar discectomy. Nov 2005.
  44. National Institute for Clinical Excellence (NICE) Interventional Procedure Guidance (IPG) 173. Percutaneous disc decompression using coblation for lower back pain. 2006.
  45. National Institute for Clinical Excellence (NICE) Interventional Procedure Guidance (IPG) 300. Interventional procedure guidance 300. Percutaneous endoscopic laser lumbar discectomy; May 2009.
  46. National Institute for Clinical Excellence (NICE) Interventional Procedure Guidance (IPG) 303. Percutaneous endoscopic laser cervical discectomy. June 2009.
  47. National Institute for Clinical Excellence (NICE). Interventional procedures overview of Laser lumbar discectomy. London, UK: NICE; August 2003.
  48. Singh V, Benyamin RM, Datta S, Falco FJ, Helm S 2nd, Manchikanti L. Systematic review of percutaneous lumbar mechanical disc decompression utilizing Dekompressor. Pain Physician. 2009 May-Jun;12(3):589-99.
  49. Singh V, Manchikanti L, Benyamin RM et al. Percutaneous lumbar laser disc decompression: a systematic review of current evidence. Pain Physician 2009; 12(3):573-88.
  50. Singh V(1), Manchikanti L, et al. Percutaneous lumbar laser disc decompression: an update of current evidence. Pain Physician. 2013 Apr;16(2 Suppl):SE229-60.
  51. Washington State Department of Labor and Industries. Percutaneous discectomy for disc herniation. Olympia, Washington: Washington State Department of Labor and Industries (WSDLI), 2004:42.
  52. Work Loss Data Institute. Low back - lumbar & thoracic (acute & chronic). Encinitas (CA): Work Loss Data Institute; 2011.
  53. Zhu H, Zhou XZ, Cheng MH, Shen YX, Dong QR. The efficacy of coblation nucleoplasty for protrusion of lumbar intervertebral disc at a two-year follow-up. Int Orthop. 2011 Nov;35(11):1677-82.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 06/26/14.

GUIDELINE UPDATE INFORMATION:

05/15/04

New Medical Coverage Guideline. Investigational.

11/15/04

Revision to guideline; consisting of the addition of CPT code 62287.

01/01/05

Annual HCPCS update: consisting of the addition of S2348.

08/15/05

Scheduled review and revision of guideline; consisting of updated references.

08/15/06

Scheduled review and revision of guideline consisting of updated references.

07/15/07

Annual review; investigational status maintained; reformatted guideline, references updated.

07/15/08

Review and revision of guideline consisting of updated references.

01/01/09

Annual HCPCS coding update: revised descriptor for code 62287.

09/15/09

Scheduled review; no change to position statement; references updated.

07/15/10

Scheduled review; position statement unchanged, references updated.

01/01/12

Annual HCPCS coding update: revised descriptor for code 62287.

07/15/12

Scheduled review; position statement revised to include additional methods of percutaneous disc decompression; policy title revised: references updated.

07/15/13

Scheduled review; position statement unchanged; Program Exceptions section updated; references updated.

07/15/14

Scheduled review; position statement unchanged; CPT codes 0274T and 0275T added; references updated.

11/01/15

Revision: ICD-9 Codes deleted.

01/01/17

Annual CPT/HCPCS update. Revised descriptors for 62287, 0274T, and 0275T. Revised Program Exceptions section.

Date Printed: June 23, 2017: 06:19 PM