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Medical Policy: 07.01.39
Original Effective Date: January 2008
Reviewed: November 2011
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy 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 will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
A variety of minimally invasive techniques have been investigated over the years as a treatment of low back pain related to disc disease. Techniques can be broadly divided into techniques that are designed to remove or ablate disc material and thus decompress the disc or those that are designed to alter the biomechanics of the disc annulus. The former category includes chymopapain injection, automated percutaneous lumbar discectomy, laser discectomy, and most recently plasma disc decompression using radiofrequency energy, often referred to using the proprietary terms Coblation® or DISC nucleoplasty™.
Automated percutaneous lumbar discectomy (APLD) is a minimally invasive surgical technique for treatment of herniated intervertebral discs. For this procedure, a thin, blunt-tipped suction and cutting probe such as the Stryker Dekompressor® Percutaneous Discectomy Probe, or the Endius® MDS MicroDebrider System, is inserted percutaneously and the terminal portion of the probe is placed into the herniated disc using fluoroscopic guidance. The device is used to suction out some or all of the degenerated central disc tissue.
A variety of different lasers have been investigated for laser discectomy, including YAG, KTP, holmium, argon, and carbon dioxide lasers. Regardless of the type of laser, the procedure involves placement of the laser within the nucleus under fluoroscopic guidance and then activated. Due to differences in absorption, the energy requirements and the rate of application differ among the lasers. In addition, it is unknown how much disc material must be removed to achieve decompression. Therefore, protocols vary according to the length of treatment, but typically the laser is activated for brief periods only.
The Disc nucleoplasty™ procedure uses bipolar radiofrequency energy in a process referred to as Coblation technology. The technique consists of small, multiple electrodes that emit a fraction of the energy required by traditional radiofrequency energy systems. The result is that a portion of nucleus tissue is ablated not with heat, but with a low-temperature plasma field of ionized particles. These particles have sufficient energy to break organic molecular bonds within tissue, creating small channels in the disc. The proposed advantage of this Coblation technology is that the procedure provides for a controlled and highly localized ablation, resulting in minimal therapy damage to surrounding tissue.
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Prior Approval:
Not applicable
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Policy:
Automated percutaneous lumbar discectomy, laser discectomy and intervertebral disc decompression using radiofrequency energy, including but not limited to Coblation® and DISC nucleoplastyTM, are considered investigational as techniques of disc decompression and the treatment of associated pain.
There is insufficient evidence to permit conclusions on net health outcomes in the absence of well-designed and executed randomized controlled trials with adequate follow-up.
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Procedure Codes and Billing Guidelines:
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To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
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CPT 62287 Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method, single or multiple levels, lumbar (eg, manual or automated percutaneous discectomy, percutaneous laser discectomy)
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HCPCS code S2348 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar
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Selected References:
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A review of the medical literature and recommendations from Wellmark’s Medical Policy Advisory Council (MPAC), a council of practicing physicians who advise and assist Wellmark in the development and implementation of medical policies. The council is comprised of primary care and specialty physicians from Iowa and South Dakota.
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The Medical Policy Reference Manual (MPRM) developed by the Blue Cross and Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
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ECRI. Laser Discectomy for the Treatment of Herniated Lumbar Discs. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2009 February 10. 8 p. (ECRI Hotline Response). Also available: http://www.ecri.org.
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ECRI. Nucleoplasty (Coblation) for Lumbar Herniated Disc and Discogenic Pain. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2009 January 27. 9 p. (ECRI Hotline Response). Also available: http://www.ecri.org.
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Gibson JNA, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database of Systematic Reviews 2007 Apr 18;(2):CD001350.
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Boswell MV, Trescot AM, et al. Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain. Pain Physician 2007; 10:7-111.
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Singh V, Derby R. Percutaneous lumbar disc decompression. Pain Physician. 2006 Apr;9(2):139-46.
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Cohen, SP, Williams, S, et al. Nucleoplasty with or without intradiscal electrothermal therapy (IDET) as a treatment for lumbar herniated disc. J Spinal Disord Tech 2005;18(SupplS):119-S124.
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Singh V, Piryani C, Liao K. Role of percutaneous disc decompression using coblation in managing chronic discogenic low back pain: a prospective, observational study. Pain Physician. 2004 Oct;7(4):419-25.
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Ahn Y, Lee SH, Park WM et al. Percutaneous endoscopic lumbar discectomy for recurrent disc herniation: surgical technique, outcome and prognostic factors of 43 consecutive cases. Spine 2004; 29(16):E326-32.
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Haines SJ, Jordan N, et al. Discectomy strategies for lumbar disc herniation: results of the LAPDOG trial. J Clin Neurosci. 2002 Jul;9(4):411-7.
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Singh V, Piryani C, et al. Percutaneous disc decompression using coblation (nucleoplasty) in the treatment of chronic discogenic pain. Pain Physician. 2002 Jul;5(3):250-9.
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Revel M, Payan C, Vallee, et al. Automated percutaneous lumbar discectomy versus chemonucleolysis in the treatment of sciatica; A randomized multicenter trial. Spine 1993;18:1-7.
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Choy DS. Percutaneous laser disc decompression (PLDD): twelve years' experience with 752 procedures in 518 patients. J Clin Laser Med Surg. 1998 Dec;16(6):325-31.
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TARGET [database online]. Plymouth Meeting (PA): ECRI Institute; 2009 Dec 28. Percutaneous disc decompression for cervical disc herniation. Available: http://ecri.org
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Konstantinovic LM, Kanjuh ZM, Milovanovic AN, et al. Acute low back pain with radiculopathy: a double-blind, randomized, placebo-controlled study. Photomed Laser Surg. 2010 Aug;28(4):553-60.
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ECRI. Laser Discectomy for the Treatment of Herniated Lumbar Discs. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2011 March 8. (ECRI Hotline Response). Also available: http://www.ecri.org.
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ECRI. Nucleoplasty (Coblation) for Lumbar Herniated Disc and Discogenic Pain. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2011 August 9. (ECRI Hotline Response). Also available: http://www.ecri.org.
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Policy History:
Date Reason Action
October 2010 Annual review Policy renewed
November 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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