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Intradiscal Electrothermal Annuloplasty, Biacuplasty, and Percutaneous Intradiscal Radiofrequency Thermocoagulation

» Summary» Procedure Codes
» Description» Selected References
» Prior Approval» Policy History
» Policy
 

Medical Policy: 07.01.12 
Original Effective Date: November 1999 
Reviewed: November 2014 
Revised: January 2014 


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: 

The term intradiscal electrothermal annuloplasty (e.g. IDET™) specifically describes a minimally invasive annuloplasty procedure used to treat chronic low-back pain related to disc disease. In an initial step, the pathogenic disc is identified using pressure-based discography. A navigable catheter with an embedded thermal resistive coil is inserted posterolaterally into the disc annulus or nucleus. The catheter is then snaked through the disc circuitously to return posteriorly. Using radiofrequency energy, electrothermal heat is then generated within the thermal resistive coil at a temperature of 90 degrees centigrade; the disc material is heated for up to 20 minutes. The procedure is not designed to coagulate, burn, or ablate tissue. The mechanism of action of pain relief is not precisely understood, but is thought to be related to either shrinkage of the collagen fibers within the annulus or destruction of the adjacent nociceptive pain fibers.

 

A very similar technique known as percutaneous intradiscal radiofrequency thermocoagulation (PIRT) uses a radiofrequency probe that is placed into the center of the disc rather than around the annulus. The Radionics RF Disc Catheter System®  has been specifically designed for this purpose. This device is activated for only 90 seconds at a temperature of 70 degrees centigrade. Based on the destruction of nociceptive pain fibers, the Radionics Disc Catheter System is similar in concept to IDET. However, the method of delivering the thermal energy is distinctly different between these two.  Again, the mechanism of action of this procedure is not precisely understood, but is thought to be related to reducing the nociceptive pain input from the free nerve ending in the outer annulus fibrosis.

 

A more recently developed annuloplasty procedure, referred to as intradiscal biacuplasty, utilizes two internally cooled radiofrequency probes placed on the posterolateral sides of the intervertebral annulus fibrosis with the goal of reducing chronic intervertebral disc-related back pain by ablating the neurons that generate pain sensations. It is proposed that by cooling the probes, a larger area may be treated during the procedure than otherwise treated with a regular needle probe.


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Prior Approval: 

 

Not applicable


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Policy: 

Percutaneous annuloplasty (e.g. intradiscal electrothermal annuloplasty, percutaneous intradiscal radiofrequency thermocoagulation, or intradiscal biacuplasty) are not covered services because they are considered investigational.  Similarly, all related procedures and materials, e.g. diskography, fluoroscopy and supplies, are not covered services.

 

Systematic reviews of the available evidence have generally found limited to no evidence to support a role for radiofrequency annuloplasty or biacuplasty. This evidence is insufficient to conclude that these procedures improve health outcomes.





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Procedure Codes and Billing Guidelines: 

  • To report provider services use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes. 
  • 22526 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level 
  • 22527 Percutaneous intradiscal electrothermal annuloplasty, one or more additional levels
  • 22899 Unlisted procedure, spine

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Selected References: 

  • Barendse GAM, Van Den Berg SGM, Kessels AHF, et al. Randomized controlled trial of percutaneous intradiscal radiofrequency thermocoagulation for chronic discogenic back pain. Spine 2000; 26:287-92.
  • Saal JA, Saal JS. Intradiscal electrothermal treatment for chronic discogenic low back pain. Spine 2000;25:2622-2627.
  • Karasek M, Bogduk N. Twelve-months follow-up of a controlled trial of intradiscal thermal annuloplasty for back pain due to internal disc disruption. Spine 2000;25:2601-2607.
  • Heary RF. Intradiscal electrothermal annuloplasty: The IDET procedure. Journal of Spinal Disorders 2001;14(4):353-360.
  • Wetzel FT, McNally TA. Treatment of chronic discogenic low back pain with intradiskal electrothermal therapy. Journal of American Academy of Orthopedic Surgeons 2002;11:6-11.
  • Wetzel FT, McNally TA, Phillips FM. Intradiscal electrothermal therapy used to manage chronic discogenic low back pain. Spine2002;27:2621-2626.
  • Lutz C. Lutz GE, Cooke PM. Treatment of chronic lumbar discogenic pain with intradiskal electrothermal therapy: a prospective outcome study. Arch Phys Med Rehabil 2003;84:23-28.
  • Pauza, KJ, Howell S, et al. A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain.  Spine J. 2004 Jan-Feb;4(1):27-35.
  • Freeman BJ, Fraser RD, et al. A randomized, double-blind, controlled trial: intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine. 2005 Nov 1;30(21):2369-77; discussion 2378.
  • ECRI Institute.  Intradiscal Electrothermal Annuloplasty for Discogenic Pain. Plymouth Meeting (PA): ECRI Instituteleave site; 2006 July 10. 7p. [ECRI hotline response].
  • TARGET [database online]. Plymouth Meeting (PA): ECRI Instituteleave site; 2008 Feb.; Intradiscal electrothermal annuloplasty for discogenic pain.
  • Kapural L et.al. Intervertebral disc biacuplasty for the treatment of lumbar discogenic pain: results of a six-month follow-up.  Pain Med. 2008 Jan-Feb;9(1):60-67.
  • ECRI Institute.  Intradiscal Electrothermal Annuloplasty for Discogenic Pain. Plymouth Meeting (PA): ECRI Instituteleave site; 2009 February 9. 7p. [ECRI hotline response].
  • Kapural L et.al. Successful treatment of lumbar discogenic pain using intradiscal biacuplasty in previously discectomized disc. Pain Prac. 2009 Mar-April;9(2):130-134.
  • TARGET [database online]. Plymouth Meeting (PA): ECRI Instituteleave site; 2009 Nov.; Intradiscal electrothermal annuloplasty for discogenic pain.
  • Helm Ii S, Deer TR, Manchikanti L, et al. Effectiveness of thermal annular procedures in treating discogenic low back pain. Pain Physician. 2012 May-Jun;15(3):E279-304.
  • Wegener B, Rieskamp K, Buttner A, et al. Experimental evaluation of the risk of extradiscal thermal damage in intradiscal electrothermal therapy (IDET). Pain Physician. 2012 Jan-Feb;15(1):E99-E106.
  • ECRI Institute. Intradiscal Electrothermal Therapy (NeuroTherm, Inc.) For Treating Discogenic Pain. Plymouth Meeting (PA): ECRI Instituteleave site; 2012 November. [Product Brief].
  • National Institute for Clinical Excellence (NICE). Interventional procedure guidance 83. Percutaneous intradiscal radiofrequency thermocoagulation for lower back painleave site. August 2004. Accessed on January 6, 2013.

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Policy History: 

 

Date                                        Reason                               Action 

January 2011                          Annual review                    Policy renewed

January 2012                          Annual review                    Policy renewed

January 2013                          Annual review                    Policy renewed

January 2014                          Annual review                    Policy revised

November 2014                       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 © 2012 American Medical Association. All Rights Reserved.

 
Contact Information
New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
  Wellmark Blue Cross and Blue Shield
  Medical Policy Analyst
  P.O. Box 9232
  Des Moines, IA 50306-9232
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