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Medical Policy: 07.01.12
Original Effective Date: November 1999
Reviewed: January 2012
Revised: April 2007
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, involves the use of two cooled radiofrequency electrodes placed on the postereolateral side of the intervertebral annulus fibrousus. It is believed that by cooling the probes, a larger area may be treated than could occur 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.
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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
- S2348 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar
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Selected References:
- Derby R et al. Intradiscal electrothermal annuloplasty. Presented at the annual meeting of the North American Spine Society, San Francisco, CA, 1998.
- Saal JA et al. Thermal characteristics of the lumbar disc: Evaluation of a novel approach to targeted Intradiscal thermal therapy. Presented at the annual meeting of the North American Spine Society, San Francisco. CA 1998.
- Saal JA et al. A novel approach to painful internal disc derangement: Collagen modulation with a thermal percutaneous navigable catheter. A prospective trial presented at the annual meeting of the North American Spine Society, San Francisco, CA 1998.
- Two recent studies of thermal disc therapy. The Back Letter 1999;14:8.
- Can thermal therapy relieve discogenic pain? The Back Letter 1999;14:1.
- 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 Institute; 2006 July 10. 7p. [ECRI hotline response]. Available: http://www.ecri.org.
- TARGET [database online]. Plymouth Meeting (PA): ECRI Institute; 2008 Feb.; Intradiscal electrothermal annuloplasty for discogenic pain. Available: http://www.ecri.org.
- 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 Institute; 2009 February 9. 7p. [ECRI hotline response]. Available: http://www.ecri.org.
- 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 Institute; 2009 Nov.; Intradiscal electrothermal annuloplasty for discogenic pain. Available: http://www.ecri.org
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Policy History:
Date Reason Action
January 2011 Annual review Policy renewed
January 2012 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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