Notification

Spinal Laminectomy


Notification Issue Date: 03/11/2020

This version of the policy will become effective on 06/15/2020. Description section was updated. Physiatry consultation requirement was added to the lumbar portion of the policy criteria section.



Medicare Advantage Policy

Title:Spinal Laminectomy
Policy #:MA11.041c

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

MEDICALLY NECESSARY

Cervical laminectomy is considered medically necessary and, therefore, covered when all of the following conditions are met:
  • Spinal cord or nerve root compression due to any of the following:
    • Spinal stenosis with or without spondylolisthesis OR
    • Ossification of the posterior longitudinal ligament or the yellow ligament OR
    • Hypertrophy of the ligamentum flavum
  • Persistent signs and symptoms that include any of the following:
    • Rapidly progressive neurologic deficits OR
    • Symptomatic cervical myelopathy (e.g., difficulty with fine movements of the hand and upper extremity, diffuse hyperreflexia, decreased sensation at a level of C5 or below, bowel and bladder incontinence) or cervical cord compression, with or without radiculopathy OR
    • Persistent debilitating pain that is refractory to at least 6 weeks of conservative nonsurgical treatment (e.g., rest and analgesics)
  • Imaging studies (e.g., magnetic resonance imaging [MRI]) confirming spinal cord compression, nerve root compression, and/or myelographic changes, at a level corresponding to the individual's signs and symptoms

Lumbar laminectomy is considered medically necessary and, therefore, covered when all of the following conditions are met; and a physiatry consultation has been completed to confirm the failures of nonsurgical options:
  • Spinal cord or nerve root compression due to spinal stenosis, with or without spondylolisthesis
  • Persistent signs and symptoms that include any of the following:
    • Rapidly progressive neurologic deficits OR
    • Persistent neurologic claudication that is refractory to at least 6 weeks of conservative nonsurgical treatment (e.g., rest and analgesics) OR
    • Persistent debilitating pain that is refractory to at least 6 weeks of conservative nonsurgical treatment (e.g., rest and analgesics)
  • Imaging studies (e.g., magnetic resonance imaging [MRI]) confirming spinal cord or nerve root compression at a level corresponding to the individual's signs and symptoms

LUMBAR DISC HERNIATION
Laminectomy is considered medically necessary and, therefore, covered for a large central disc herniation in the spinal canal when an iatrogenic neurological deficit would be a risk with a less invasive unilateral laminotomy approach to discectomy.

SPINAL LESIONS
Laminectomy (cervical, thoracic, lumbar) is also considered medically necessary and, therefore, covered for lesions of the spinal cord/canal, including primary or metastatic tumors, abscesses, or other localized infections.

NOT MEDICALLY NECESSARY

All other uses for spinal laminectomy are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the treatment of illness or injury.
Policy Guidelines

Conservative nonsurgical treatment typically includes ALL of the following:
  • Use of prescription strength analgesics for several weeks at a dose sufficient to induce a therapeutic response
  • Analgesics should include anti-inflammatory medications with or without adjunctive medications such as nerve membrane stabilizers or muscle relaxants
  • Participation in at least 6 weeks of a medically prescribed physical therapy program (including active exercise) or documentation of why the individual could not tolerate physical therapy
  • Evaluation and appropriate management of associated cognitive, behavioral, or addiction issues
  • Documentation of compliance with the preceding criteria

Persistent debilitating pain is defined as:
  • Significant level of pain on a daily basis defined on a visual analog scale (VAS) as greater than 4 AND
  • Pain on a daily basis that has a documented impact on activities of daily living in spite of optimal conservative nonsurgical therapy as outlined above and appropriate for the individual

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, spinal laminectomy is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Description

Laminectomy is a decompressive surgical procedure intended to relieve pressure on the spinal cord or nerve roots. A portion of the vertebra, known as the lamina, is removed to decompress the spine. The removal of the lamina allows greater space for the spinal cord and nerve roots, thereby relieving compression on these structures. Foraminotomy and laminotomy involve removal of a portion of the bony arch, or lamina, on the dorsal surface of a vertebra. These are typically performed to access the disc space and relieve pressure on the nerve roots and spinal cord.

The most common diagnosis for which laminectomy is performed is spinal stenosis. Spinal stenosis describes a condition in which there is diminished space available for the neural and vascular elements in the spine, secondary to degenerative changes in the spinal canal. Symptoms may include gluteal and/or lower extremity pain, as well as fatigue, which may occur with or without back pain. Other conditions that cause pressure on the spine and nerve roots include when a mass lesion, such as a tumor, is present, abscess, or other localized infection.

During laminectomy, an incision is made in the back over the affected region, and the back muscles are dissected to expose the spinal cord. The lamina is removed from the vertebral body, along with any inflamed or thickened ligaments that may be contributing to compression. Following resection, the muscles are reapproximated and the tissue is sutured back into place. There are numerous variations on the laminectomy procedure, including minimally invasive techniques. Spinal fusion may also be combined with laminectomy when instability of the spine is present preoperatively, or if the procedure is extensive enough to expect postoperative spinal instability. Complications of laminectomy may include injuries to the spinal cord and nerve root. Some studies estimate the incidence of these injuries to be up to 10%. Worsening myelopathy and/or radiculopathy may occur in a small percentage of individuals.

Spinal osteotomy procedures are reported when a portion or portions of the vertebral segment or segments is (are) cut and removed in preparation for realigning the spine as part of a spinal deformity correction. These procedures may be required for congenital, developmental, and degenerative spinal deformities.

Corpectomy typically reflects a longitudinal resection of the vertebral body from disc space to disc space often resulting in a destabilization of the complex. In the cervical spine, at least 50% of the vertebral body is removed and in the thoracic/lumbar spine, at least 30% of the corpus is removed.

PEER-REVIEWED LITERATURE

In a prospective comparative study, Weinstein et al. (2007) evaluated the safety and effectiveness of standard decompressive laminectomy, with or without fusion, when compared to nonsurgical conservative treatment. Individuals with at least 12 weeks of symptoms and image-confirmed degenerative spondylolisthesis were enrolled in a randomized cohort (n=304) or an observational cohort (n=303). The primary outcome measurements were the Short-Form 36-Item General Health Survey (SF-36; 100-point scales, with higher scores indicating less severe symptoms) and the modified Oswestry Disability Index (ODI; 100-point scale, with lower scores indicating less severe symptoms) at up to 2 years. The one-year crossover rates were high in the randomized cohort, but moderate in the observational cohort. The intent-to-treat analysis for the randomized cohort revealed no statistically significant effects for the primary outcomes. The as-treated analysis for both cohorts combined indicated a statistically significant advantage for surgery at 3 months that increased at 1-year and diminished slightly at 2-year follow-up. There was minimal evidence of harm from either the surgical or nonsurgical treatments. The authors concluded that in non-randomized as-treated comparisons, individuals with degenerative spondylolisthesis and spinal stenosis had a substantially greater improvement in pain and function when treated surgical compared with individuals who were treated non-surgically. The study is limited in its heterogeneous study design and cross-over.

In a follow-up study (i.e., Spine Patient Outcomes Research Trial [SPORT]), Weinstein et al. (2009) evaluated four-year results from the Weinstein et al. (2007) study. In the randomized cohort (n=304), 66% who were randomized to receive surgery received it by 4 years whereas 54% of those randomized to receive nonsurgical treatment received surgery by 4 years. In the observational cohort (n=303), 97% of those who chose surgery received it whereas 33% of those who chose nonsurgical treatment eventually received surgery. The as-treated analysis combining the randomized and observational cohorts demonstrated that the clinically relevant advantages of surgery that were reported at 2-year follow-up were maintained at 4 years. The authors concluded that compared with individuals who were treated non-surgically, individuals with degenerative spondylolisthesis and associated spinal stenosis who were treated surgically maintained substantially greater pain relief and improvement in functional status at 4 years. The study is limited in its heterogeneous study design and cross-over.

In a systematic review, Chou et al. (2009) evaluated the available peer-reviewed literature to assess the safety and effectiveness of surgery for non-radicular back pain with common degenerative changes, radiculopathy with herniated lumbar disc, and symptomatic spinal stenosis. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by Cochrane Back Review Group and Oxman. For individuals with symptomatic spinal stenosis with or without degenerative spondylolisthesis, the authors found good evidence indicating that decompressive laminectomy was moderately superior to nonsurgical treatment through 2 years.

In a prospective, multi-center study, Fehlings et al. (2013) evaluated the safety and effectiveness of decompressive laminectomy in individuals with cervical spondylotic myelopathy. A total of 278 individuals with mild (n=85), moderate (n=110), and severe (n=83) cervical spondylotic myelopathy were enrolled. Ultimately, one-year follow-up data was available for 85.4% of participants (n=222). Outcome measurements included the Japanese Orthopedic Association scoring system (i.e., JOA; score of 0 to 17, with lower scores indicating more severe deficits), SF-36, and the neck disability index (NDI; higher scores indicating more severe disability). There was a statistically significant improvement from baseline to one-year follow-up in the JOA, NDI, and all SF-36 health dimensions, with the exception of general health (p < 0.05). With the exception of JOA, the degree of improvement did not depend on the severity of preoperative symptoms. Fifty-two individuals experienced complications, with no significant differences among the severity groups. The authors concluded that decompressive laminectomy for the treatment of cervical spondylotic myelopathy was associated with improvement in functional, disability-related, and quality of life outcomes for all disease severity categories. The study is limited in its lack of comparisons with an appropriate control group, short-term follow-up period, and heterogeneous patient population.

In a retrospective analysis of the SPORT study, Rihn et al. (2015) evaluated whether standard decompressive laminectomy was safe and effective compared to nonsurgical treatment in the octogenarian population. Individuals who were at least 80 years of age (n=105) were compared with those younger than 80 years of age (n=1,130) in this as-treated analysis. A total of 58 individuals in the octogenarian group and 749 of the younger individuals underwent surgery. In addition to ODI and SF-36, other outcome measurements included intra- and post-operative complications, reoperation, and postoperative mortality. There were no differences in complication, reoperation, and postoperative mortality rates between the older and younger groups. However, averaged over the 4-year follow-up period, individuals in the octogenarian group who were treated operatively had significantly greater improvement in ODI and most SF-36 domains. The authors concluded that there were no significant increases in complication and mortality rates following surgery in the octogenarian population compared with younger individuals. In addition, they noted that operative treatment of lumbar stenosis and degenerative spondylolisthesis offered significant benefit over nonsurgical treatment. The study is limited in its heterogeneous study design and cross-over.

SUMMARY

Laminectomy is a surgical procedure in which a portion of the vertebra (the lamina) is removed to decompress the spinal cord. Removal of the lamina creates greater space for the spinal cord and the nerve roots, thus relieving compression on these structures. Laminectomy is typically performed to alleviate compression due to spinal stenosis or a space-occupying lesion.

For individuals who have lumbar spinal stenosis and spinal cord or nerve root compression who receive lumbar laminectomy, the evidence includes randomized controlled trials (RCTs) and nonrandomized comparative studies. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity.In patients with spinal stenosis, there is sufficient evidence that laminectomy is more effective than nonoperative “usual care” in individuals with spinal stenosis who do not improve after eight weeks of conservative treatment. The superiority of laminectomy is sustained through up to eight years of follow-up. This conclusion applies best to individuals who do not want to undergo intensive, organized conservative treatment, or who do not have access to such a program. For individuals who want to delay surgery and participate in an organized program of physical therapy and exercise, early surgery with the combination of conservative initial treatment and delayed surgery in selected patients have similar outcomes at two years. From a policy perspective, this means that immediate laminectomy and intensive conservative care are both viable options.The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have cervical spinal stenosis and spinal cord or nerve root compression who receive cervical laminectomy, the evidence includes RCTs and nonrandomized comparative studies. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. There is a lack of high-quality, comparative evidence for this indication, although what evidence there is offers outcomes similar to those for lumbar spinal stenosis. Given the parallels between cervical laminectomy and lumbar laminectomy, a chain of evidence can be developed that the benefit reported for lumbar laminectomy supports a benefit for cervical laminectomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have space-occupying lesion(s) of the spinal canal or nerve root compression who receive cervical, thoracic, or lumbar laminectomy, the evidence includes case series. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. Most case series are small and retrospective. They have reported that most patients with myelopathy experience improvements in symptoms or abatement of symptom progression after laminectomy. However, this uncontrolled evidence does not provide a basis to determine the efficacy of the procedure compared with alternatives. The evidence is insufficient to determine the effects of the technology on health outcomes.

The current standard of care, clinical input, clinical practice guidelines, and the absence of alternative treatments all support the use of laminectomy for space-occupying lesions of the spinal canal. As a result, laminectomy may be considered medically necessary for patients with space-occupying lesions of the spinal cord.


References

American College of Occupational and Environmental Medicine (ACOEM). Cervical and thoracic spine disorders. 2011. Available online at: http://www.guideline.gov/content.aspx?id=35207&search=cervical+fusion. Accessed November 01, 2017.

Amundsen T, Weber H, Nordal HJ, et al. Lumbar spinal stenosis: conservative or surgical management?: A prospective 10-year study. Spine (Phila Pa 1976). 2000;25(11):1424-1435; discussion 1435-1426.

Atlas SJ, Keller RB, Wu YA, et al. Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the maine lumbar spine study. Spine (Phila Pa 1976). 2005;30(8):936- 943.

Chou R, Baisden J, Carragee EJ, et al. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine (Phila Pa 1976). 2009;34(10):1094-1109.

Epstein NE. Laminectomy for cervical myelopathy. Spinal Cord. 2003;41(6):317-327.

Fehlings MG, Smith JS, Kopjar B, et al. Perioperative and delayed complications associated with the surgical treatment of cervical spondylotic myelopathy based on 302 patients from the AOSpine North America Cervical Spondylotic Myelopathy Study. J Neurosurg Spine. 2012;16(5):425-432.

Fehlings MG, Wilson JR, Kopjar B, et al. Efficacy and safety of surgical decompression in patients with cervical spondylotic myelopathy: results of the AOSpine North America prospective multi-center study. J Bone Joint Surg Am. 2013;95(18):1651-1658.

Ghogawala Z, Benzel EC, Heary RF, et al. Cervical spondylotic myelopathy surgical trial: randomized, controlled trial design and rationale. Neurosurgery. 2014;75(4):334-346.

Kadanka Z, Mares M, Bednanik J, et al. Approaches to spondylotic cervical myelopathy: conservative versus surgical results in a 3-year follow-up study. Spine (Phila Pa 1976). 2002;27(20):2205-2210; discussion 2210-2201.

Kommu R, Sahu BP, Purohit AK. Surgical outcome in patients with cervical ossified posterior longitudinal ligament: A single institutional experience. Asian J Neurosurg. 2014;9(4):196-202.

Lee CH, Jahng TA, Hyun SJ, et al. Expansive laminoplasty versus laminectomy alone versus laminectomy and fusion for cervical ossification of the posterior longitudinal ligament: is there a difference in the clinical outcome and sagittal alignment? Clin SpineSurg. 2016;29(1):E9-E15.

Lurie JD, Tosteson TD, Tosteson A, et al. Long-term outcomes of lumbar spinal stenosis: eight-year results of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2015;40(2):63-76.

Malmivaara A, Slatis P, Heliovaara M, et al. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine (Phila Pa 1976). 2007;32(1):1-8.

Manzano GR, Casella G, Wang MY, et al. A prospective, randomized trial comparing expansile cervical laminoplasty and cervical laminectomy and fusion for multilevel cervical myelopathy. Neurosurgery. 2012;70(2):264-277.

North American Spine Society. Clinical guideline: Diagnosis and treatment of degenerative lumbar spinal stenosis. 2011; Available at: https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/LumbarStenosis.pdf. Accessed November 01, 2017.

Okada M, Minamide A, Endo T, et al. A prospective randomized study of clinical outcomes in patients with cervical compressive myelopathy treated with open-door or French-door laminoplasty. Spine (Phila Pa 1976). 2009;34(11):1119-1126.

Piccolo R, Passanisi M, Chiaramonte I, et al. Cervical spinal epidural abscesses. A report on five cases. J Neurosurg Sci. 1999;43(1):63-67.

Rihn JA, Hilibrand AS, Zhao W, et al. Effectiveness of surgery for lumbar stenosis and degenerative spondylolisthesis in the octogenarian population: analysis of the Spine Patient Outcomes Research Trial (SPORT) data. J Bone Joint Surg Am. 2015;97(3):177-85.

Sampath P, Bendebba M, Davis JD, et al. Outcome of patients treated for cervical myelopathy. A prospective, multicenter study with independent clinical review. Spine (Phila Pa 1976). 2000;25(6):670-676.

Tredway TL, Santiago P, Hrubes MR, et al. Minimally invasive resection of intradural-extramedullary spinal neoplasms. Neurosurgery. 2006;58(1 Suppl):ONS52-58; discussion ONS52-58.

Wang L, Song Y, Liu L, et al. Clinical outcomes of two different types of open-door laminoplasties for cervical compressive myelopathy: a prospective study. Neurol India. 2012;60(2):210-216.

Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med. 2007;356(22):2257-2270.

Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009;91(6):1295-1304.

Zong S, Zeng G, Xiong C, et al. Treatment results in the differential surgery of intradural extramedullary schwannoma of 110 cases. PLoS One. 2013;8(5):e63867.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

CERVICAL SPINE

63001, 63015, 63045, 63048, 63050, 63051, 63180, 63182, 63185, 63190, 63191, 63194
63196, 63198, 63250, 63265, 63270

THORACIC SPINE
63003, 63016, 63046, 63271, 63276, 63281, 63286

THORACOLUMBAR SPINE
63252, 63287

LUMBAR SPINE
63005, 63012, 63017, 63047, 63048, 63185, 63190, 63200, 63267, 63272, 63277, 63282, 63290

SACRAL SPINE
63011



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Report the most appropriate diagnosis code in support of medical necessity as listed in the policy.


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Misc Code

N/A:

N/A


Coding and Billing Requirements






Policy History

Revisions for MA11.041c:
06/15/2020This version of the policy will become effective on 06/15/2020. Description section was updated. Physiatry consultation requirement was added to the lumbar portion of the policy criteria section.


Revisions for MA11.041b:
01/14/2019This version of the policy will become effective on 01/14/2019.

Definitions of spinal osteotomy and corpectomy procedures were added to the description section.

Revisions for MA11.041a:
01/02/2018This version of the policy will become effective on 01/02/2018.

The policy has been reviewed to communicate the Company’s continuing position on Spinal Laminectomy.

The following language was added to the description section:

Foraminotomy and laminotomy involve removal of a portion of the bony arch, or lamina, on the dorsal surface of a vertebra. These are typically performed to access the disc space and relieve pressure on the nerve roots and spinal cord.

For LUMBAR DISC HERNIATION, the following policy statement was added:

Laminectomy is considered medically necessary and, therefore, covered for a large central disc herniation in the spinal canal when an iatrogenic neurological deficit would be a risk with a less invasive unilateral laminotomy approach to discectomy.

Additional procedures codes related to foraminotomy and laminotomy were added to the policy.

Revisions from MA11.041:
08/03/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on Spinal Laminectomy.
01/01/2016This policy will become effective 01/01/2016.

New policy MA11.041 has been developed to communicate the Company coverage criteria for spinal laminectomy.





Version Effective Date: 06/15/2020
Version Issued Date: 06/15/2020
Version Reissued Date: N/A