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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.

02-20000-48

Original Effective Date: 07/01/15

Reviewed: 09/28/17

Revised: 10/15/17

Subject: Lumbar Spine Surgery

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:

Lumbar spinal stenosis is narrowing of the spinal column or of the neural foramina where spinal nerves leave the spinal column, causing pressure on the spinal nerves. The most common cause is degenerative changes in the lumbar spine. Neurogenic claudication is the most common symptom, referring to leg symptoms encompassing the buttock, groin and anterior thigh, as well as radiation down the posterior part of the leg to the feet.

Degenerative lumbar spondylolisthesis is the displacement of a vertebra in the lower part of the spine; one lumbar vertebra slips forward on another with an intact neural arch and begins to press on nerves. The slippage occurs at the L4-L5 level most commonly. The most common cause, in adults, is degenerative disease although it may also result from bone diseases and fractures.

Spondylosis is an umbrella term describing age-related degeneration of the spine. Lumbar degenerative disease without stenosis or spondylolisthesis is characterized by disabling low back pain and spondylosis at L4-5, L5-S1, or both levels.

Spine surgery is a complex area of medicine. Operative treatment is indicated only when the natural history of an operatively treatable problem is better than the natural history of the problem without operative treatment. Choice of surgical approach is based on anatomy, the candidate’s pathology, and the surgeon's experience and preference. All operative interventions must be based on a positive correlation with clinical findings, the natural history of the disease, the clinical course, and diagnostic tests or imaging results. In general, operative treatment is indicated if the program of non-operative treatment fails.

Lumbar microdiscectomy is a surgical procedure to remove part of the damaged spinal disc. The damaged spinal disc herniates into the spinal canal and irritates the nerve roots. Nerve root compression leads to symptoms like low back pain, radicular pain, numbness and tingling, muscular weakness, and paresthesia. Typical disc herniation pain is exacerbated with any movement that causes the disc to increase pressure on the nerve roots.

Lumbar laminectomy, facetectomy and foraminotomy are common decompression surgeries. The most common indication for decompression surgery is spinal stenosis. Spondylolisthesis and herniated disk are also frequent indications. Decompression surgery is usually performed as part of lumbar fusion surgery.

Lumbar spinal fusion (arthrodesis) is a surgical procedure used to treat spinal conditions of the lumbar spine, e.g., degenerative disc disease, spinal stenosis, injuries/fractures of the spine, spinal instability, and spondylolisthesis. Spinal fusion is a “welding” process that permanently fuses or joins together two or more adjacent bones in the spine, immobilizing the vertebrae and restricting motion at a painful joint. It is usually performed after other surgical procedures of the spine, such as discectomy or laminectomy. Fusions can be performed either anteriorly, laterally, or posteriorly, or via a combined approach.

POSITION STATEMENT:

Lumbar Microdiscectomy

Lumbar microdiscectomy meets the definition of medical necessity for the following:

• Inter-vertebral disc herniation when all of the following are met:

• Primary radicular symptoms that hinder daily activities noted on clinical exam, AND

• Failure to improve with conservative treatment, defined as documented failure of at least 6 consecutive weeks of ANY TWO (2) of the following physician-directed conservative treatments:

Analgesics, steroids, and/or NSAIDs

Structured program of physical therapy

Structured home exercise program prescribed by a physical therapist, chiropractic provider, or physician

Epidural steroid injections and/or facet injections/selective nerve root block, AND

• Imaging studies show evidence of inter-vertebral disc herniation

• As the first line of treatment (no conservative treatment required) in the following clinical scenarios:

• Progressive nerve compression resulting in an acute neurologic deficit (sensory or motor) due to herniated disc, OR

• Cauda equina syndrome (loss of bowel or bladder control)

Lumbar Decompression (Laminectomy, Laminotomy, Facetectomy and Foraminotomy)

Lumbar spinal canal decompression using laminectomy, facetectomy or foraminotomy meets the definition of medical necessity for the following:

• Lumbar spinal stenosis when all of the following are met:

• Low back pain with neurogenic claudication or radicular leg pain that impairs daily activities for at least twelve (12) weeks, AND

• Failure to improve with of conservative treatment, defined as documented failure of at least 6 consecutive weeks of ANY TWO (2) of the following physician-directed conservative treatments:

Analgesics, steroids, and/or NSAIDs

Structured program of physical therapy

Structured home exercise program prescribed by a physical therapist, chiropractic provider, or physician

Epidural steroid injections and/or facet injections/selective nerve root block, AND

• Imaging findings demonstrate moderate to severe stenosis consistent with clinical signs/symptoms

OR

• As the first line of treatment (no conservative treatment required) in the following clinical scenarios:

• Progressive nerve compression resulting in an acute neurologic (sensory or motor) deficit

• Cauda equina syndrome (loss of bowel or bladder control)

• Spinal stenosis due to tumor, infection, or trauma

Lumbar Spine Fusion (single level with or without decompression)

Lumbar spine fusion at a single level, with or without decompression, meets the definition of medical necessity for the following:

• Lumbar back pain with neurogenic claudication, and/or radicular leg pain without sensory or motor deficit that impairs daily activities for at least 6 months, AND

• Failure to improve with conservative treatment, defined as documented failure of at least 6 consecutive weeks (6 months for isolated low back pain) of ANY TWO (2) of the following physician-directed conservative treatments:

Analgesics, steroids, and/or NSAIDs

Structured program of physical therapy

Structured home exercise program prescribed by a physical therapist, chiropractic provider, or physician

Epidural steroid injections and/or facet injections/selective nerve root block, AND

• Imaging studies correspond to the clinical findings, AND

• At least one of the following clinical conditions exists:

• Spondylolisthesis (neural arch defect: spondylolytic spondylolisthesis, degenerative spondylolisthesis, or congenital unilateral neural arch hypoplasia), OR

• Evidence of segmental instability (excessive motion, as in degenerative spondylolisthesis, segmental instability, and intra-operative or surgically induced segmental instability). Surgically induced segmental instability is instability that will be or is produced during a surgical procedure. Removal of greater than 50% of the bilateral facets or complete unilateral facetectomy is required. Documentation of moderate to severe foraminal stenosis by radiological exam/report is required. The operating surgeon must document in the medical record that the instability is anticipated, OR

• Revision of previous failed surgery for pseudoarthrosis at the same level, at least 6-12 months after initial surgery, if significant functional gains are anticipated, OR

• Revision of previous failed surgery for disc herniations if significant functional gains are anticipated, OR

• Fusion for the treatment of spinal tumor, cancer, or infection

OR

• As the first line of treatment (no conservative treatment required) in the following clinical scenarios:

• Progressive nerve compression resulting in an acute neurologic deficit (sensory or motor)

• Cauda equina syndrome (loss of bowel or bladder control)

Repeat Lumbar Spine Fusion

Repeat lumbar fusion surgeries are reviewed on a case-by-case basis upon submission of medical records and imaging studies that demonstrate remediable pathology. The items below will also be required:

• Rationale as to why fusion is preferred over other non-invasive or less invasive treatment procedures

• Signed documentation that the member has participated in the decision-making process and understands the high rate of failure and complications

Lumbar Spine Fusion (multi-level with or without decompression)

NOTE*: All multi-level fusion surgeries are reviewed on a case-by-case basis.

Lumbar spine fusion at multiple levels, with or without decompression, meets the definition of medical necessity for the following:

• Lumbar back pain, neurogenic claudication, and/or radicular leg pain (without sensory or motor deficit) that impairs daily activities for at least 6 months, AND

• Failure to improve with conservative treatment, defined as documented failure of at least 6 consecutive weeks of ANY TWO (2) OF the following physician-directed conservative treatments:

Analgesics, steroids, and/or NSAIDs

Structured program of physical therapy

Structured home exercise program prescribed by a physical therapist, chiropractic provider, or physician

Epidural steroid injections and/or facet injections/selective nerve root block, AND

• Imaging studies correspond to the clinical findings, AND

• At least one of the following clinical conditions:

• Multiple level spondylolisthesis (Note: Fusions in cases with single level spondylolisthesis should be limited to the unstable level), OR

• Fusion for the treatment of spinal tumor, trauma, cancer, or infection affecting multiple levels, OR

• Intra-operative or surgically induced segmental instability. Surgically induced segmental instability is instability that will be or is produced during a surgical procedure. Removal of greater than 50% of the bilateral facets or complete unilateral facetectomy is required. Documentation of moderate to severe foraminal stenosis by radiological exam/report is required. The operating surgeon must document in the medical record that the instability is anticipated.

• As the first line of treatment (no conservative treatment required) for progressive nerve compression resulting in an acute neurologic deficit (sensory or motor), AND one of the aforementioned clinical conditions

NOTE**: Instrumentation, bone formation or grafting materials, including biologics, should be limited to FDA approved devices or biologics and indications.

Lumbar Artificial Disc

Artificial lumbar disc replacement is considered experimental or investigational. There is a lack of clinical data to permit conclusions on net health outcomes.

Conservative treatment

Musculoskeletal conservative treatment includes a combination of modalities, such as rest, ice, heat, modified activities, medical devices (crutches, immobilizer, metal braces, orthotics, rigid stabilizer or splints, not to include neoprene sleeves), medications, diathermy, chiropractic treatments, or physician supervised home exercise program. Part of this combination may include the physician instructing member to rest the area or stay off the injured part.

Home Exercise Program

A home exercise program must include both of the following elements:

• Member is provided an exercise prescription/plan

• Follow up with member is conducted regarding completion of HEP (after suitable 4-6 week period), or inability to complete HEP due to a physical reason (e.g., increased pain, inability to physically perform exercises; member inconvenience or noncompliance without explanation does not constitute an inability to complete HEP)

Contraindications to spine surgery:

• Medical contraindications (e.g., severe osteoporosis; infection of soft tissue adjacent to the spine, whether or not it has spread to the spine; severe cardiopulmonary disease; anemia; malnutrition; systemic infection)

• Non-physiologic modifiers of pain presentation or non-operative conditions mimicking radiculopathy or instability (e.g., peripheral neuropathy, piriformis syndrome, myofascial pain, sympathetically mediated pain syndromes, sacroiliac dysfunction, psychological conditions)

• Active tobacco use prior to fusion surgery (stopping smoking for at least six weeks prior to surgery and during the period of fusion healing is generally recommended)

• Morbid obesity (significant risk and concern for improper post-operative healing, post-operative complications related to morbid obesity, and/or an inability to participate in post-operative rehabilitation)

BILLING/CODING INFORMATION:

CPT Coding

0163T

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional interspace, lumbar (List separately in addition to code for primary procedure) (investigational)

0164T

Removal of total disc arthroplasty, (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure) (investigational)

0165T

Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure) (investigational)

22533

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

22534

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure)

22558

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

22585

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)

22612

Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)

22614

Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)

22630

Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar

22632

Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure)

22633

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar

22634

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure)

22857

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar (investigational)

22862

Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar (investigational)

22865

Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar (investigational)

63005

Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis

63012

Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)

63017

Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar

63030

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar

63035

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure)

63042

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar

63044

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace (List separately in addition to code for primary procedure)

63047

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar

63048

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)

63056

Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)

63057

Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure)

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 Determination (NCD) was reviewed on the last guideline reviewed date: Lumbar ARTIFICIAL DISC Replacement (LADR) (150.10), located at cms.gov.

The following Local Coverage Determinations (LCDs) were reviewed on the last guideline reviewed date: Noncovered Services (L29288); Lumbar Spinal Fusion for Instability and Degenerative Disc Conditions (L32076), located at fcso.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

02-20000-45, Cervical Spine Surgery

OTHER:

None applicable.

REFERENCES:

  1. Atlas, S.J., Keller, R.B., Wu, Y.A., Deyo, R.A., & Singer, D.E. (2005). Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the Maine lumbar spine study. Spine, 30(8), 936-43.
  2. Blue Cross Blue Shield Association Medical Policy Reference Manual. 7.01.87, Artificial Intervertebral Disc: Lumbar Spine. February 2015.
  3. Blue Cross Blue Shield Association Medical Policy Reference Manual. 7.01.141, Lumbar Fusion. December 2014.
  4. Blue Cross Blue Shield Association Medical Policy Reference Manual. 7.01.145, Laminectomy. January 2015.
  5. Blue Cross Blue Shield Association Medical Policy Reference Manual. 7.01.146, Discectomy. December 2014.
  6. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Artificial lumbar disc arthroplasty. TEC Assessments. 2013; Volume 28, Tab 7.
  7. Deyo RA, Hickam D, Duckart JP, Piedra M. Complications after surgery for lumbar stenosis in a veteran population. Spine (Phila Pa 1976). 2013 Sep 1;38(19):1695-702.
  8. Deyo, R.A., Mirza, S.K., Martin, B.I., Kreuter, W., Goodman, D.C., & Jarvik, J.G. (2010). Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA, 303(13), 1259-1265.
  9. First Coast Service Options, Inc. (FCSO). LCD for Lumbar Spinal Fusion for Instability and Degenerative Disc Conditions (L32076), 01/13.
  10. First Coast Service Options, Inc. (FCSO). LCD for Noncovered Services (L29288), 04/15.
  11. Centers for Medicare and Medicaid Services. NCD for Lumbar ARTIFICIAL DISC Replacement (LADR) (150.10). 08/07.
  12. Kang K, Rodriguez-Olaverri JC, Schwab F, Hashem J, Razi A, Farcy JP. Partial facetectomy for lumbar foraminal stenosis. Adv Orthop. 2014;2014:534658.
  13. McClelland S 3rd, Kim SS. Successful operative management of an upper lumbar spinal canal stenosis resulting in multilevel lower nerve root radiculopathy. J Neurosci Rural Pract. 2015 Jan;6(1):108-11.
  14. National Imaging Associates, Inc. Lumbar Spinal Fusion Surgery Clinical Guideline, 2016.
  15. National Imaging Associates, Inc. Lumbar Spinal Fusion Surgery Clinical Guideline, 2017.
  16. National Imaging Associates, Inc. Lumbar Decompression Procedures Clinical Guideline, 2016.
  17. National Imaging Associates, Inc. Lumbar Decompression Procedures Clinical Guideline, 2017.
  18. National Imaging Associates, Inc. Lumbar Microdiscectomy Clinical Guideline, 2016.
  19. National Imaging Associates, Inc. Lumbar Microdiscectomy Clinical Guideline, 2017.
  20. Nerland US, Jakola AS, Solheim O, Weber C, Rao V, Lønne G, Solberg TK, Salvesen Ø, Carlsen SM, Nygaard ØP, Gulati S. Minimally invasive decompression versus open laminectomy for central stenosis of the lumbar spine: pragmatic comparative effectiveness study. BMJ. 2015 Apr 1;350:h1603.
  21. North American Spine Society (NASS). (2009). Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis. doi: 10.1016/j.spinee.2009.03.016.
  22. North American Spine Society Coverage Policy Recommendations: Lumbar Artificial Disc Replacement. April 30, 2014. Accessed at https://www.spine.org.
  23. Tosteson, ANA, et al. (2008). Surgical treatment of spinal stenosis with and without degenerative spondylolisthesis: Cost-effectiveness after 2 years. Ann Intern Med, 149(2), 845-853.
  24. Weinstein, J.N., Lurie, J.D., Tosteson, T.D., Hanscom, B., Tosteson, A.N.A., Blood E.A., Hu, S.S. (2007). Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med., 356(22), 2257-2270.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 09/28/17.

GUIDELINE UPDATE INFORMATION:

07/01/15

New Medical Coverage Guideline.

04/15/17

Revision: clarified requirements for conservative treatment by adding additional detail; revised criteria for lumbar decompression (laminectomy, laminotomy, facetectomy and foraminotomy), single level fusion, and multi-level fusion. Updated references.

10/15/17

Revision: updated position statement section regarding intra-operative/surgically induced segmental instability.

Date Printed: December 18, 2017: 03:23 PM