Notification

Spinal Discectomy


Notification Issue Date: 10/16/2018

This version of the policy will become effective on 01/14/2019.

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



Medical Policy Bulletin


Title:Spinal Discectomy

Policy #:11.14.29c

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

MEDICALLY NECESSARY

LUMBAR DISCECTOMY
Lumbar discectomy is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • Signs and symptoms of radiculopathy are present on history and physical exam
  • Either of the following clinical presentation is present:
    • Rapidly progressing neurologic deficits OR
    • Persistent debilitating back or leg pain that is refractory to at least six weeks of conservative treatment (e.g., analgesics, physical therapy including active exercise)
  • Documentation of nerve root compression on imaging (e.g., magnetic resonance imaging [MRI] or computed tomography [CT]) at a level that corresponds with the individual's symptoms

CERVICAL DISCECTOMY
Cervical discectomy is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • Signs and symptoms of radiculopathy and/or myelopathy is present on history and physical exam
  • Any of the following clinical presentations are present:
    • Rapidly progressing neurologic deficits OR
    • Persistent debilitating neck, back, or arm pain that is refractory to at least six weeks of conservative treatment (e.g., rest and analgesics) OR
    • Persistent or progressive symptoms of myelopathy that are refractory to at least six weeks of conservative treatment (e.g., rest and analgesics)
  • Documentation of nerve root compression on imaging (e.g., MRI or CT) at a level that corresponds with the individual's symptoms

NOT MEDICALLY NECESSARY

All other uses for spinal discectomy 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.
Guidelines

Radiculopathy presents with a characteristic set of signs and symptoms as follows:

HISTORY
  • Pain that radiates down the back of the leg to below the knee
  • Numbness and tingling in a dermatomal distribution
  • Muscular weakness in a pattern associated with spinal nerve root compression

PHYSICAL EXAM
  • Positive straight leg raise test
  • Loss of deep tendon reflexes corresponding to affected nerve root level
  • Loss of sensation in a dermatomal distribution

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 six 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 four 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 benefit contract, spinal discectomy is covered under the medical benefits of the Company's products when the medical necessity criteria listed in this medical policy are met.

Description

Herniation, or extrusion, of an intervertebral disc can compress the spinal nerves and result in symptoms of radiculopathy including pain, numbness, and weakness. The natural history of untreated disc herniations is not well-characterized, but most will decrease in size over time due to shrinking and/or regression of the disc. In conjunction, clinical symptoms also tend to improve. Therefore, initial care often consists of conservative treatment, including rest, analgesics, and/or a prescribed activity program tailored to the individual. Cervical myelopathy often involves pain-related symptoms of the upper extremities and legs as well as bowel and bladder function. It results from disruption or interruption of normal neural transmission in the spinal cord and may be caused by degenerative processes including intervertebral disc herniation, inflammation, or tumors.

Depending on the cause of radiculopathy and/or myelopathy, symptoms may resolve over time with conservative treatment. A small proportion of individuals may have rapidly progressive signs or symptoms, which may involve risk for irreversible neurologic deficits. Other individuals may have persistent, but non-progressive symptoms, which may require further intervention. For these individuals, there is a high degree of morbidity and functional disability associated with chronic back pain. Therefore, surgical treatment may also be considered.

Discectomy is a surgical procedure in which one or more intervertebral discs are removed. It is intended to treat symptoms associated with disc herniation, by relieving pressure on the affected nerve(s). Lumbar discectomy can be performed by a variety of surgical approaches. Open discectomy is the traditional approach, in which a 2 to 3 cm incision is made over the area to be repaired. The spinal muscles are dissected and a portion of the lamina may be removed to allow access to the vertebral space. The extruded disc is removed either entirely or partially using direct visualization. Osteophytes that are protruding into the vertebral space may also be removed if necessary. An alternative to open discectomy is microdiscectomy. It is a minimally invasive procedure that involves a smaller incision, visualization by means of a special camera, and removal of disc fragments using specialized instruments. The amount of resection that can be performed during microdiscectomy is less and therefore, the procedure is typically reserved for small herniations.

Cervical discectomy is often performed with an anterior open approach, in which the cervical spine is accessed through an incision in the anterior neck. Soft tissue and muscle are separated to expose the spine. The disc is then removed using direct visualization. This procedure can be performed with or without spinal fusion, but is most commonly performed with fusion in a procedure known as anterior cervical discectomy and fusion (ACDF). Posterior cervical discectomy and foraminotomy is a less invasive procedure performed through a small incision in the back of the neck. The nerves and muscle are separated using a small retractor and the spine is visualized with microscopic guidance, and a portion of the spine, known as the foramen, is removed to expose the spinal canal. Specialized instruments are used to remove a portion or the entire disc.

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, randomized controlled trial, Buttermann et al. (2004) evaluated the safety and effectiveness of epidural steroid injections when compared with standard discectomy in individuals with lumbar herniated nucleus pulposus. A total of 169 individuals with a large herniation (i.e., > 25 percent of the cross-sectional area of the spinal canal) were followed over a three year period. Of these individuals, 100 participants who had no improvement after a minimum of six weeks of nonsurgical treatment were randomized 1:1 to receive either epidural steroid injection (n=50) or surgical discectomy (n=50). Individuals who underwent discectomy had the most rapid decrease in symptoms, with up to 98 percent of participants reporting that the treatment had been successful. Up to 56 percent of the individuals who received an epidural steroid injection reported that the treatment had been effective. Those who did not obtain relief from the steroid injections had a subsequent discectomy and their outcomes did not appear to be have been adversely affected by the delay in surgery. The authors concluded that epidural steroid injections were not as effective as discectomy with respect to reducing symptoms and disability associated with a large herniation of the lumbar disc.

In a prospective observational cohort study (i.e., Spine Patient Outcomes Research Trial [SPORT]), Weinstein et al. (2006) compared the safety and effectiveness of standard open discectomy with nonsurgical treatment for individuals with lumbar disc herniation. Of the 743 individuals initially enrolled in the observational cohort, ultimately 528 individuals were treated with discectomy and 191 received nonsurgical treatment. Outcome measurements included the Short Form-36 (SF-36) bodily pain and physical function scores and the modified Oswestry Disability Index (ODI). At three month follow-up, individuals who chose discectomy had a significantly greater improvement in the outcome measurements. These differences somewhat narrowed at two year follow-up. The authors concluded that there was improvement with both surgical and nonsurgical treatment among individuals with persistent sciatica from lumbar disc herniation. However, those who chose surgical treatment reported greater improvements that those who elected nonsurgical treatment. The study is limited in its lack of randomization and relatively mid-term follow-up period.

In a prospective randomized controlled trial, Peul et al. (2007) evaluated the safety and effectiveness of early discectomy when compared with nonsurgical conservative treatment in individuals who had persistent sciatica that did not resolve within six weeks. The primary outcome measurements were the Roland Disability Questionnaire, visual-analogue scale (VAS) pain score, and the individual's report of perceived recovery. Study participants were followed for one year. Of the 141 individuals assigned to undergo surgery, 89 percent (n=125) underwent discectomy after a mean of 2.2 weeks. Of the 142 individuals designated for conservative treatment, 39 percent (n=55) were treated surgically after a mean of 18.7 weeks. There was no statistically significant difference in disability scores during the first year (p = 0.13). However, individuals assigned to the early discectomy group reported a faster rate of perceived recovery (p < 0.001; hazard ratio = 1.97). The authors concluded that one year outcomes were similar for individuals assigned to early surgery and those assigned to conservative treatment. However, the rates of pain relief and perceived recovery were faster for those assigned to early discectomy. The study is limited in its short-term follow-up period.

In a systematic review, Chou et al. (2009) evaluated the available peer-reviewed literature to assess the safety and effectiveness of surgery for nonradicular back pain with common degenerative changes, radiculopathy with herniated lumbar disc, and symptomatic spinal stenosis. All relevant studies were methodologically assessed by two independent reviewers using criteria developed by Cochrane Back Review Group and Oxman. For individuals with radiculopathy with herniated lumbar disc, the authors found good evidence indicating that standard open discectomy and microdiscectomy were moderately superior to nonsurgical treatment for improvement in pain and function through three months.

In 2016, Gugliotta et al. published a prospective cohort study comparing open discectomy (n=297) with conservative treatment (n=73) for lumbar disc herniation. Assignment to treatment group was decided by physicians based on individuals’ clinical indications. Conservative treatment consisted of active physical therapy, education, and nonsteroidal anti-inflammatory drugs. Outcomes were the North American Spine Society (NASS) scores (back pain, neurogenic, function) and SF-36 scores (physical and mental function). Follow-up measurements were obtained at 6 weeks, 12 weeks, 1 year, and 2 years. Of the three different NASS scores measured at the four different follow-up times, the statistically significant differences in the surgery group over the conservative treatment group were in the NASS back pain score at six weeks and the NASS function score at one year. SF-36 physical and mental function scores were comparable between treatment groups at all follow-up points.

SUMMARY

Discectomy has been established as a surgical treatment for individuals with disc herniation refractory to conservative treatment, which may include rest and analgesics. In 2011, the American College of Occupational and Environmental Medicine (ACOEM) published practice guidelines on cervical and thoracic spine disorders. They provided consensus-based recommendations, noting that for radicular pain syndromes, cervical discectomy with fusion was recommended in individuals with chronic radiculopathy due to ongoing nerve root compression, with persistent and debilitating pain, refractory to at least six weeks of non-operative therapy. Decompressive surgery including discectomy with fusion was recommended for individuals with myelopathy. In 2012, the NASS issued evidence-based clinical guidelines on the diagnosis and treatment of lumbar disc herniation with radiculopathy. They provided a grade B recommendation (i.e., fair evidence; level II or III studies with consistent findings), noting that discectomy appeared to be effective for both short and long-term relief. Despite any methodological limitations of the available evidence, there are numerous studies that indicate consistent improvement with lumbar discectomy for rapid resolution of pain and disability among individuals who are refractory to conservative treatment. And while there is considerably less evidence available for cervical discectomy compared with lumbar discectomy, they are not substantially different in its conclusions. Therefore, based on the available peer-reviewed literature and relevant published guidelines, discectomy appears to improve symptoms and disability in individuals with persistent, debilitating symptoms related to herniated disc and persistent radiculopathy or myelopathy despite conservative treatment.
References


American Academy of Neurology (AAN). Use of epidural steroid injections to treat lumbosacral radicular pain. 2007; Available at: https://www.aan.com/Guidelines/Home/GetGuidelineContent/250. Accessed September 18, 2017.

American College of Occupational and Environmental Medicine (ACOEM). Cervical and thoracic spine disorders. 05/27/2016. Available at: https://www.dir.ca.gov/dwc/ForumDocs/Implementing-AB-1124-Drug-Formularyand-update-of-MTUS-Guideline/Cervical-Thoracic-Spine.pdf. Accessed September 18, 2017.

Arts MP, Brand R, van den Akker E, et al. The NEtherlands Cervical Kinematics (NECK) trial. Cost-effectiveness of anterior discectomy with or without interbody fusion and arthroplasty in the treatment of cervical disc herniation; a double-blind randomised multicenter study. BMC Musculoskelet Disord. 2010;11.

Atlas SJ, Keller RB, Wu YA, et al. Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study. Spine (Phila Pa 1976). 2005;30(8):927-935.

Bono CM, Ghiselli G, Gilbert TJ, et al. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011;11(1):64-72.

Buttermann GR. Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. A prospective, randomized study. J Bone Joint Surg Am. 2004;86-A(4):670-679.
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.

Erginousakis D, Filippiadis DK, Malagari A, et al. Comparative prospective randomized study comparing conservative treatment and percutaneous disk decompression for treatment of intervertebral disk herniation. Radiology. 2011;260(2):487-493.

Faught RW, Church EW, Halpern CH, et al. Long-term quality of life after posterior cervical foraminotomy for radiculopathy. Clin Neurol Neurosurg.2016;142:22-25.

Fehlings MG, Barry S, Kopjar B, Yoon ST, et al. Anterior versus posterior surgical approaches to treat cervical spondylotic myelopathy: outcomes of the prospective multicenter AOSpine North America CSM study in 264 patients. Spine (Phila Pa 1976). 2013;38(26):2247-52.

Gugliotta M, da Costa BR, Dabis E, et al. Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open. 2016;6(12):e012938.

He J, Xiao S, Wu Z, et al. Microendoscopic discectomy versus open discectomy for lumbar disc herniation: a meta-analysis. Eur Spine J. 2016;25(5):1373-1381.

Henriksen L, Schmidt K, Eskesen V, et al. A controlled study of microsurgical versus standard lumbar discectomy. Br J Neurosurg. 1996;10(3):289-293.

Jacobs WC, van Tulder M, Arts M, et al. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. Eur Spine J. 2011;20(4):513-522.

Katayama Y, Matsuyama Y, Yoshihara H, et al. Comparison of surgical outcomes between macro discectomy and micro discectomy for lumbar disc herniation: a prospective randomized study with surgery performed by the same spine surgeon. J Spinal Disord Tech. 2006;19(5):344-347.

Lewis RA, Williams NH, Sutton AJ, et al. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. Spine J. 2015;15(6):1461-1477.

Mu X, Wei J, Li P. What were the advantages of microendoscopic discectomy for lumbar disc herniation comparing with open discectomy: a meta-analysis? Int J Clin Exp Med. 2015;8(10):17498-17506.

National Institute for Health and Care Excellence (NICE). IPG141 Automated percutaneous mechanical lumbar discectomy. November 2005; Available at:
http://www.nice.org.uk/guidance/IPG141/chapter/1-guidance. Accessed September 18, 2017.

Nikolaidis I, Fouyas IP, Sandercock PA, et al. Surgery for cervical radiculopathy or myelopathy. Cochrane Database Syst Rev. 2010(1):CD001466.

North American Spine Society. Clinical guideline: Diagnosis and treatment of lumbar herniated disc with radiculopathy. 2012; Available at: www.spine.org/Documents/ResearchClinicalCare/Guidelines/LumbarDiscHerniation.pdf. Accessed September 18, 2017.

Osterman H, Seitsalo S, Karppinen J, et al. Effectiveness of microdiscectomy for lumbar disc herniation: a randomized controlled trial with 2 years of follow-up. Spine (Phila Pa 1976). 2006;31(21):2409-2414.

Peolsson A, Soderlund A, Engquist M, et al. Physical function outcome in cervical radiculopathy patients after physiotherapy alone compared with anterior surgery followed by physiotherapy: a prospective randomized study with a 2-year follow-up. Spine (Phila Pa 1976). 2013;38(4):300-307.

Persson LC, Moritz U, Brandt L, et al. Cervical radiculopathy: pain, muscle weakness and sensory loss in patients with cervical radiculopathy treated with surgery, physiotherapy or cervical collar. A prospective, controlled study. Eur Spine J. 1997;6(4):256-266.

Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007;356(22):2245-2256.

van Geest S, Kuijper B, Oterdoom M, et al. CASINO: surgical or nonsurgical treatment for cervical radiculopathy, a randomised controlled trial. BMC Musculoskelt Disord. 2014;15.

Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976). 1983;8(2):131-140.

Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA. 2006;296(20):2451-2459.

Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006;296(20):2441-2450.





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)

63020, 63030, 63035, 63040, 63042, 63043, 63044, 63056, 63057, 63075, 63076


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)

M50.00 Cervical disc disorder with myelopathy, unspecified cervical region

M50.01 Cervical disc disorder with myelopathy, high cervical region

M50.020 Cervical disc disorder with myelopathy, mid-cervical region, unspecified level

M50.021 Cervical disc disorder at C4-C5 level with myelopathy

M50.022 Cervical disc disorder at C5-C6 level with myelopathy

M50.023 Cervical disc disorder at C6-C7 level with myelopathy

M50.03 Cervical disc disorder with myelopathy, cervicothoracic region

M50.10 Cervical disc disorder with radiculopathy, unspecified cervical region

M50.11 Cervical disc disorder with radiculopathy, high cervical region

M50.120 Mid-cervical disc disorder, unspecified

M50.121 Cervical disc disorder at C4-C5 level with radiculopathy

M50.122 Cervical disc disorder at C5-C6 level with radiculopathy

M50.123 Cervical disc disorder at C6-C7 level with radiculopathy

M50.13 Cervical disc disorder with radiculopathy, cervicothoracic region

M50.20 Other cervical disc displacement, unspecified cervical region

M50.21 Other cervical disc displacement, high cervical region

M50.220 Other cervical disc displacement, mid-cervical region, unspecified level

M50.221 Other cervical disc displacement at C4-C5 level

M50.222 Other cervical disc displacement at C5-C6 level

M50.223 Other cervical disc displacement at C6-C7 level

M50.23 Other cervical disc displacement, cervicothoracic region

M51.05 Intervertebral disc disorders with myelopathy, thoracolumbar region

M51.06 Intervertebral disc disorders with myelopathy, lumbar region

M51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar region

M51.16 Intervertebral disc disorders with radiculopathy, lumbar region

M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region

M51.25 Other intervertebral disc displacement, thoracolumbar region

M51.26 Other intervertebral disc displacement, lumbar region

M51.27 Other intervertebral disc displacement, lumbosacral region



HCPCS Level II Code Number(s)



S2350 Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, single interspace

S2351 Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, each additional interspace (list separately in addition to code for primary procedure)


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions for 11.14.29c:
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 from 11.14.29b:
12/01/2017This version of the policy will become effective 12/01/2017.

The following CPT code has been removed from this policy: 62380. Policy addresses criteria for open discectomy or micordiscectomy.

The following ICD-10 CM codes have been added to this policy:
M50.00, M50.01, M50.020, M50.021, M50.022, M50.023, M50.03, M50.10, M50.11, M50.120, M50.121, M50.122, M50.123, M50.13, M50.20, M50.21, M50.220, M50.221, M50.222, M50.223, M50.23, M51.05, M51.06, M51.15, M51.16, M51.17, M51.25, M51.26, M51.27


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/14/2019
Version Issued Date: 01/14/2019
Version Reissued Date: N/A

Connect with Us        


2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.