Natinal Imaging Assciates, Inc. Clinical guidelines LUMBAR SPINE SURGERY: LUMBAR SPINAL FUSION LUMBAR DECOMPRESSION LUMBAR MICRODISCECTOMY Original Date: July 1, 2015 Page 1 f 6 FOR FLORIDA BLUE MEMBERS ONLY Key Primary CPT Cdes: Refer t pages: 5-6 Last Review Date: May 28, 2015 Medical Cverage Guideline Number: Last Revised Date: 02-20000-48 Respnsible Department: Implementatin Date: July 2015 Clinical Operatins INTRODUCTION: FOR FLORIDA BLUE MEMBERS ONLY Lumbar spinal stensis is narrwing f the spinal clumn r f the neural framina where spinal nerves leave the spinal clumn, causing pressure n the spinal crd. The mst cmmn cause is degenerative changes in the lumbar spine. Neurgenic claudicatin is the mst cmmn symptm, referring t leg symptms encmpassing the buttck, grin and anterir thigh, as well as radiatin dwn the psterir part f the leg t the feet. Degenerative lumbar spndyllisthesis is the displacement f a vertebra in the lwer part f the spine; ne lumbar vertebra slips frward n anther with an intact neural arch and begins t press n nerves. The slippage ccurs at the L4-L5 level mst cmmnly. The mst cmmn cause, in adults, is degenerative disease althugh it may als result frm bne diseases and fractures. Spndylsis is an umbrella term describing age-related degeneratin f the spine. Lumbar degenerative disease withut stensis r spndyllisthesis is characterized by disabling lw back pain and spndylsis at L4-5, L5-S1, r bth levels. Spine surgery is a cmplex area f medicine. Operative treatment is indicated nly when the natural histry f an peratively treatable prblem is better than the natural histry f the prblem withut perative treatment. Chice f surgical apprach is based n anatmy, the candidate s pathlgy, and the surgen's experience and preference. All perative interventins must be based n a psitive crrelatin with clinical findings, the natural histry f the disease, the clinical curse, and diagnstic tests r imaging results. In general, perative treatment is indicated if the prgram f nn-perative treatment fails. Lumbar micrdiscectmy is a surgical prcedure t remve part f the damaged spinal disc. The damaged spinal disc herniates int the spinal canal and irritates the nerve rts. Nerve rt cmpressin leads t symptms like lw back pain, radicular pain, numbness and tingling, muscular weakness, and paresthesia. Typical disc herniatin pain is exacerbated with any mvement that causes the disc t increase pressure n the nerve rts. 1 Lumbar Spine Surgery Flrida Blue Prprietary
Lumbar laminectmy, facetectmy and framintmy are cmmn decmpressin surgeries. The mst cmmn indicatin fr decmpressin surgery is spinal stensis. Spndyllisthesis and herniated disk are als frequent indicatins. Decmpressin surgery is usually perfrmed as part f lumbar fusin surgery. Lumbar spinal fusin (arthrdesis) is a surgical prcedure used t treat spinal cnditins f the lumbar spine, e.g., degenerative disc disease, spinal stensis, injuries/fractures f the spine, spinal instability, and spndyllisthesis. Spinal fusin is a welding prcess that permanently fuses r jins tgether tw r mre adjacent bnes in the spine, immbilizing the vertebrae and restricting mtin at a painful jint. It is usually perfrmed after ther surgical prcedures f the spine, such as discectmy r laminectmy. Fusins can be perfrmed either anterirly, laterally, r psterirly, r via a cmbined apprach. CLINICAL INDICATIONS: Lumbar Micrdiscectmy Lumbar micrdiscectmy meets the definitin f medical necessity fr the fllwing: Inter-vertebral disc herniatin when all f the fllwing are met: Primary radicular symptms that hinder daily activities nted n clinical exam, AND Failure t imprve with at least six cnsecutive weeks f cnservative treatment, AND Imaging studies shw evidence f inter-vertebral disc herniatin As the first line f treatment (n cnservative treatment required) in the fllwing clinical scenaris: Prgressive nerve cmpressin resulting in an acute neurlgic deficit (sensry r mtr) due t herniated disc, OR Cauda equina syndrme (lss f bwel r bladder cntrl) Lumbar Decmpressin (Laminectmy, Facetectmy and Framintmy) Lumbar spinal canal decmpressin using laminectmy, facetectmy r framintmy meets the definitin f medical necessity fr the fllwing: OR Lumbar spinal stensis when all f the fllwing are met: Lw back pain, neurgenic claudicatin, and/r radicular leg pain that impairs daily activities fr at least twelve (12) weeks, AND Failure t imprve with at least 6 weeks f cnservative treatment, AND Imaging findings are cnsistent with clinical signs/symptms, AND Imaging studies d nt shw evidence f spinal instability As the first line f treatment (n cnservative treatment required) in the fllwing clinical scenaris: Prgressive nerve cmpressin resulting in an acute neurlgic (sensry r mtr) deficit Cauda equina syndrme (lss f bwel r bladder cntrl) Spinal stensis due t tumr, infectin, r trauma 2 Lumbar Spine Surgery Prprietary
Lumbar Spine Fusin (single level with r withut decmpressin) Lumbar spine fusin at a single level, with r withut decmpressin, meets the definitin f medical necessity fr the fllwing: Lumbar back pain, neurgenic claudicatin, and/r radicular leg pain withut sensry r mtr deficit that impairs daily activities fr at least 6 mnths, AND Failure t imprve with least 6-12 weeks f cnservative treatment, AND Imaging studies crrespnd t the clinical findings, AND At least ne f the fllwing clinical cnditins exists: Spndyllisthesis (neural arch defect: spndyllytic spndyllisthesis, degenerative spndyllisthesis, r cngenital unilateral neural arch hypplasia), OR Evidence f segmental instability (excessive mtin, as in degenerative spndyllisthesis, segmental instability, and surgically induced segmental instability), OR Revisin f previus failed surgery fr pseudarthrsis at the same level, at least 6-12 mnths after initial surgery, if significant functinal gains are anticipated, OR Revisin f previus failed surgery fr disc herniatins if significant functinal gains are anticipated, OR OR Fusin fr the treatment f spinal tumr, cancer, r infectin, OR Chrnic lw back pain r degenerative disc disease must have failed at least 6 mnths f apprpriate nn-perative treatment (cmprehensive rehabilitatin) (will be evaluated n a case-by-case basis). As the first line f treatment (n cnservative treatment required) in the fllwing clinical scenaris: Prgressive nerve cmpressin resulting in an acute neurlgic deficit (sensry r mtr) Cauda equina syndrme (lss f bwel r bladder cntrl) Repeat Lumbar Spine Fusin Repeat lumbar fusin surgeries are reviewed n a case-by-case basis upn submissin f medical recrds and imaging studies that demnstrate remediable pathlgy. The items belw will als be required: Ratinale as t why fusin is preferred ver ther nn-invasive r less invasive treatment prcedures Signed dcumentatin that the has participated in the decisin-making prcess and understands the high rate f failure and cmplicatins Lumbar Spine Fusin (multi-level with r withut decmpressin) NOTE*: All multi-level fusin surgeries are reviewed n a case-by-case basis. Lumbar spine fusin at multiple levels, with r withut decmpressin, meets the definitin f medical necessity fr the fllwing: Lumbar back pain, neurgenic claudicatin, and/r radicular leg pain (withut sensry r mtr deficit) that impairs daily activities fr at least 6 mnths, AND Failure t imprve with least 6-12 weeks f cnservative treatment, AND Imaging studies crrespnd t the clinical findings, AND 3 Lumbar Spine Surgery Prprietary
At least ne f the fllwing clinical cnditins: Multiple level spndyllisthesis, OR Fusin fr the treatment f spinal tumr, trauma, cancer, r infectin affecting multiple levels, OR Intra-perative segmental instability As the first line f treatment (n cnservative treatment required) fr prgressive nerve cmpressin resulting in an acute neurlgic deficit (sensry r mtr), AND ne f the afrementined clinical cnditins NOTE**: Instrumentatin, bne frmatin r grafting materials, including bilgics, shuld be limited t FDA apprved devices r bilgics and indicatins. Lumbar Artificial Disc Artificial lumbar disc replacement is cnsidered experimental r investigatinal. There is a lack f clinical data t permit cnclusins n net health utcmes. Cnservative treatment Musculskeletal cnservative treatment includes a cmbinatin f mdalities, such as rest, ice, heat, mdified activities, medical devices (crutches, immbilizer, metal braces, rthtics, rigid stabilizer r splints, nt t include neprene sleeves), medicatins, diathermy, chirpractic treatments, r physician supervised hme exercise prgram. Part f this cmbinatin may include the physician instructing member t rest the area r stay ff the injured part. Hme Exercise Prgram A hme exercise prgram must include bth f the fllwing elements: 1. Member is prvided an exercise prescriptin/plan 2. Fllw up with member is cnducted regarding cmpletin f HEP (after suitable 4-6 week perid), r inability t cmplete HEP due t a physical reasn (e.g., increased pain, inability t physically perfrm exercises; member incnvenience r nncmpliance withut explanatin des nt cnstitute an inability t cmplete HEP) Cntraindicatins t spine surgery: Medical cntraindicatins (e.g., severe steprsis; infectin f sft tissue adjacent t the spine, whether r nt it has spread t the spine; severe cardipulmnary disease; anemia; malnutritin; systemic infectin) Nn-physilgic mdifiers f pain presentatin r nn-perative cnditins mimicking radiculpathy r instability (e.g., peripheral neurpathy, pirifrmis syndrme, myfascial pain, sympathetically mediated pain syndrmes, sacriliac dysfunctin, psychlgical cnditins) Active tbacc use prir t fusin surgery (stpping smking fr at least six weeks prir t surgery and during the perid f fusin healing is generally recmmended) Mrbid besity (significant risk and cncern fr imprper pst-perative healing, pst-perative cmplicatins related t mrbid besity, and/r an inability t participate in pst-perative rehabilitatin 4 Lumbar Spine Surgery Prprietary
BILLING/CODING INFORMATION: CPT Cding: 0163T Ttal disc arthrplasty (artificial disc), anterir apprach, including discectmy t prepare interspace (ther than fr decmpressin), each additinal interspace, lumbar (List separately in additin t cde fr primary prcedure) (investigatinal) 0164T Remval f ttal disc arthrplasty, (artificial disc), anterir apprach, each additinal interspace, lumbar (List separately in additin t cde fr primary prcedure) (investigatinal) 0165T Revisin including replacement f ttal disc arthrplasty (artificial disc), anterir apprach, each additinal interspace, lumbar (List separately in additin t cde fr primary prcedure) (investigatinal) 22533 Arthrdesis, lateral extracavitary technique, including minimal discectmy t prepare interspace (ther than fr decmpressin); lumbar 22534 Arthrdesis, lateral extracavitary technique, including minimal discectmy t prepare interspace (ther than fr decmpressin); thracic r lumbar, each additinal vertebral segment (List separately in additin t cde fr primary prcedure) 22558 Arthrdesis, anterir interbdy technique, including minimal discectmy t prepare interspace (ther than fr decmpressin); lumbar 22585 Arthrdesis, anterir interbdy technique, including minimal discectmy t prepare interspace (ther than fr decmpressin); each additinal interspace (List separately in additin t cde fr primary prcedure) 22612 Arthrdesis, psterir r psterlateral technique, single level; lumbar (with lateral transverse technique, when perfrmed) 22614 Arthrdesis, psterir r psterlateral technique, single level; each additinal vertebral segment (List separately in additin t cde fr primary prcedure) 22630 Arthrdesis, psterir interbdy technique, including laminectmy and/r discectmy t prepare interspace (ther than fr decmpressin), single interspace; lumbar 22632 Arthrdesis, psterir interbdy technique, including laminectmy and/r discectmy t prepare interspace (ther than fr decmpressin), single interspace; each additinal interspace (List separately in additin t cde fr primary prcedure) 22633 Arthrdesis, cmbined psterir r psterlateral technique with psterir interbdy technique including laminectmy and/r discectmy sufficient t prepare interspace (ther than fr decmpressin), single interspace and segment; lumbar 22634 Arthrdesis, cmbined psterir r psterlateral technique with psterir interbdy technique including laminectmy and/r discectmy sufficient t prepare interspace (ther than fr decmpressin), single interspace and segment; each additinal interspace and segment (List separately in additin t cde fr primary prcedure) 22857 Ttal disc arthrplasty (artificial disc), anterir apprach, including discectmy t prepare interspace (ther than fr decmpressin), single interspace, lumbar (investigatinal) 22862 Revisin including replacement f ttal disc arthrplasty (artificial disc), 5 Lumbar Spine Surgery Prprietary
anterir apprach, single interspace; lumbar (investigatinal) 22865 Remval f ttal disc arthrplasty (artificial disc), anterir apprach, single interspace; lumbar (investigatinal) 63005 Laminectmy with explratin and/r decmpressin f spinal crd and/r cauda equina, withut facetectmy, framintmy r discectmy (eg, spinal stensis), 1 r 2 vertebral segments; lumbar, except fr spndyllisthesis 63012 Laminectmy with remval f abnrmal facets and/r pars inter-articularis with decmpressin f cauda equina and nerve rts fr spndyllisthesis, lumbar (Gill type prcedure) 63017 Laminectmy with explratin and/r decmpressin f spinal crd and/r cauda equina, withut facetectmy, framintmy r discectmy (eg, spinal stensis), mre than 2 vertebral segments; lumbar 63030 Lamintmy (hemilaminectmy), with decmpressin f nerve rt(s), including partial facetectmy, framintmy and/r excisin f herniated intervertebral disc; 1 interspace, lumbar 63035 Lamintmy (hemilaminectmy), with decmpressin f nerve rt(s), including partial facetectmy, framintmy and/r excisin f herniated intervertebral disc; each additinal interspace, cervical r lumbar (List separately in additin t cde fr primary prcedure) 63042 Lamintmy (hemilaminectmy), with decmpressin f nerve rt(s), including partial facetectmy, framintmy and/r excisin f herniated intervertebral disc, reexplratin, single interspace; lumbar 63044 Lamintmy (hemilaminectmy), with decmpressin f nerve rt(s), including partial facetectmy, framintmy and/r excisin f herniated intervertebral disc, reexplratin, single interspace; each additinal lumbar interspace (List separately in additin t cde fr primary prcedure) 63047 Laminectmy, facetectmy and framintmy (unilateral r bilateral with decmpressin f spinal crd, cauda equina and/r nerve rt[s], [eg, spinal r lateral recess stensis]), single vertebral segment; lumbar 63048 Laminectmy, facetectmy and framintmy (unilateral r bilateral with decmpressin f spinal crd, cauda equina and/r nerve rt[s], [eg, spinal r lateral recess stensis]), single vertebral segment; each additinal segment, cervical, thracic, r lumbar (List separately in additin t cde fr primary prcedure) 63056 Transpedicular apprach with decmpressin f spinal crd, equina and/r nerve rt(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, r lateral extraframinal apprach) (eg, far lateral herniated intervertebral disc) 63057 Transpedicular apprach with decmpressin f spinal crd, equina and/r nerve rt(s) (eg, herniated intervertebral disc), single segment; each additinal segment, thracic r lumbar (List separately in additin t cde fr primary prcedure) 6 Lumbar Spine Surgery Prprietary