Coblation®, Laser Discectomy and Automated Percutaneous Disc Decompression Printer-Friendly Version   

Medical Policy: 07.01.39 
Original Effective Date: January 2008 
Reviewed:  
Revised:  

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

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.

Policy: 

Effective January 1, 2008 Automated percutaneous lumbar discectomy, laser discectomy and intervertebral disc decompression using radiofrequency energy, including but not limited to Coblation® and DISC nucleoplasty^TM, are considered investigational as techniques of disc decompression and the treatment of associated pain.

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
• CPT code 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)
• 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: 

• 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.
• 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.
• Gibson JNA, Waddell G.  Surgical interventions for lumbar disc prolapse.  Cochrane Database of Systematic Reviews 2007 Apr 18;(2):CD001350.
• 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.
• Singh V, Derby R. Percutaneous lumbar disc decompression. Pain Physician. 2006 Apr;9(2):139-46.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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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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
Station 304
636 Grand Ave
Des Moines, Iowa 50309

*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.

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.