Medical Policy: 07.01.39
Original Effective Date: January 2008
Reviewed: July 2016
Revised: July 2016
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.
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 automated percutaneous lumbar discectomy, laser discectomy, percutaneous laminectomy, and most recently plasma disc decompression using radiofrequency energy, often referred to using the proprietary terms Coblation® or DISC nucleoplasty™.
Automated Percutaneous Discectomy
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.
Percutaneous Lysis of Adhesions
Lysis of epidural adhesions, also called the Racz procedure, involves passage of a catheter (Racz catheter) endoscopically or percutaneously, using fluoroscopic guidance, with epidural injections of hypertonic saline in conjunction with corticosteroids and analgesics, has been investigated as a treatment option. Theoretically, the use of hypertonic saline results in a mechanical disruption of the adhesions. It may also function to reduce edema within previously scarred and/or inflamed nerves. Finally, manipulating the catheter at the time of the injection may disrupt adhesions. Spinal endoscopy has been used to guide the lysis procedure, but the procedure is more commonly performed percutaneously using epidurography to guide catheter placement and identify nonfilling adhesions that indicate epidural scarring. Using endoscopy guidance, a flexible fiberoptic catheter is inserted into the sacral hiatus, providing 3-D visualization to steer the catheter toward the adhesions, to more precisely place the injectate in the epidural space and onto the nerve root. Various protocols for lysis have been described; in some situations the catheter may remain in place for several days for serial treatment sessions.
Sacroiliac Joint Fusion
Sacroiliac joint fusion, whether performed as an open or minimally invasive (percutaneous) surgical procedure, with or without bone grafts and other metal implant devices, has been proposed as a treatment for individuals who are unresponsive to or cannot tolerate other therapy for chronic low back pain due to sacroiliac joint syndrome and other pain-related sacroiliac conditions.
Sacroiliac Joint Syndrome-Sacroiliac joint problems are referred to by varying terms, including sacroiliac joint dysfunction, sacroiliac joint inflammation, sacroiliac joint strain, and sacroiliac joint syndrome. Each of these terms refers to a condition that causes pain in the sacroiliac joint area from a variety of causes. Individuals often experience pain in the lower back and hips, but pain may also be present in the groin and thighs; this pain is often aggravated by any form of movement including sitting, lifting, running or walking. The cause of sacroiliac joint inflammation and pain can be difficult to diagnose since the sacroiliac joint is not easily palpated or manipulated, radiographs or other imaging studies are often normal, and other conditions (for example, degenerative arthritis, lower back pain, sciatica) can cause similar symptoms.
Clinical Guidelines and Recommendations
In April 2013, the American Society of Interventional Pain Physicians published a guideline update titled “An Update of Comprehensive Evidence-based Guidelines for Interventional Techniques in Chronic Spinal Pain. Part II: Guidance and Recommendations” in the journal Pain Physician. In this update, authors assessed the recommendation for a number of variations of percutaneous lumbar discectomy. Recommendations state: The evidence for various modes of percutaneous disc decompression is limited to fair for nucleoplasty, and limited for [automated percutaneous lumbar discectomy] APLD, percutaneous lumbar disc decompression, and decompressor.
In 2012, the North American Spine Society released “Clinical Guidelines for Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy.”Recommendations state: There is insufficient evidence to make a recommendation for or against the use of tubular discectomy compared with open discectomy to improve the outcomes.
In 2015 North American Spinal Society wrote a positive guideline: The NASS coverage policy also included:
Due to the relatively moderate evidence, it is particularly critical that inclusion criteria are scrutinized and patient selection is executed with vigilance. The procedure itself has proven to be relatively safe. There is a valid concern for bias in that the overwhelming majority of the data produced so far has been industry-sponsored and generally composed of case series. However there are some data on five-year outcomes that demonstrate sustained benefit that does not appear to degrade from 1 year to 5 year time-points. The committee will revisit the quality of forthcoming evidence as it is produced in re-evaluations of the indications and coverage of this procedure.
At this time, no evidence-based guidelines regarding sacroiliac spinal fusion procedures are available from the American Association of Neurological Surgeons (AANS), American Academy of Orthopaedic Surgeons (AAOS) or theAmerican Pain Society (APS),).
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.
Clinical studies have not established any clinically significant benefit of use of a laser over use of a scalpel for percutaneous lumbar diskectomy.
Percutaneous lysis of epidural adhesions, with or without endoscopic guidance, are considered investigational. Techniques used either alone or in combination include mechanical disruption with a catheter and/or injection of hypertonic solutions with steroids, analgesics, or hyaluronidase.
Minimally invasive sacroiliac joint fusion and percutaneous sacroiliac joint fusion procedures, including the use of iFuse, ISymmetry, or other devices are considered investigational for all indications, including but not limited to: sacral insufficiency fractures, sacroiliac (SI) joint pain and chronic back pain.
Open Sacroiliac joint fusion procedures are considered medically necessary for any of the following indications:
- As an adjunct to sacrectomy or partial sacrectomy related to tumors involving the sacrum; OR
- As an adjunct to the medical treatment of sacroiliac joint infection/sepsis; OR
- Severe traumatic injuries associated with pelvic ring fracture; OR
- During multisegment spinal constructs (for example, correction of deformity in scoliosis or kyphosis surgery) extending to the ilium.
The current evidence on sacroiliac joint fusion is insufficient to permit conclusions regarding the clinical effectiveness of the procedures, whether performed as an open or minimally invasive (percutaneous) surgical procedure, with or without bone grafts and other metal implant devices, for individuals who are unresponsive to or cannot tolerate other therapy for chronic low back pain due to sacroiliac joint syndrome, sacral insufficiency fractures, and other pain-related sacroiliac conditions. Assessment of the data is mixed and insufficient to support long-term efficacy and safety of open sacroiliac joint fusion for the treatment of chronic back pain, or to establish its effectiveness compared with more conservative alternatives. Prospective trials with standardized selection criteria are needed to identify the role of sacroiliac joint fusion procedures in the management of individuals with these conditions refractory to conservative management.
Procedure Codes and Billing Guidelines:
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device
27280 Arthrodesis, open, sacroiliac joint, including obtaining bone graft, including instrumentation, when performed
62263 Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days
62264 Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day
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)
C2614 Probe, percutaneous lumbar discectomy
G0276 Blinded procedure for lumbar stenosis, percutaneous image-guided lumbar decompression (PILD) or placebo-control, performed in an approved coverage with evidence development (CED) clinical tria
- S2348 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar
0274T - Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic
0275T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar
- 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.
Yakovlev A, Tamimi MA, Liang H, Eristavi M. Outcomes of percutaneous disc decompression utilizing nucleoplasty for the treatment of chronic discogenic pain. Pain Physician. 2007 Mar;10(2):319-28.
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.
TARGET [database online]. Plymouth Meeting (PA): ECRI InstituteExternal Site
; 2009 Dec 28. Percutaneous disc decompression for cervical disc herniation.
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.
ECRI. Laser Discectomy for the Treatment of Herniated Lumbar Discs. Plymouth Meeting (PA): ECRI InstituteExternal Site
; 2011 March 8. (ECRI Hotline Response).
ECRI. Nucleoplasty (Coblation) for Lumbar Herniated Disc and Discogenic Pain. Plymouth Meeting (PA): ECRI InstituteExternal Site
; 2011 August 9. (ECRI Hotline Response).
ECRI. Dekompressor Lumbar Discectomy for Treating Disc Herniation. Plymouth Meeting (PA): ECRI InstituteExternal Site
; 2012 February 2. [Hotline Response].
ECRI. Laser Discectomy for Treating Herniated Lumbar Discs. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2012 September 10. [Hotline Response].
Singh V, Manchikanti L, Calodney AK et al. Percutaneous lumbar laser disc decompression: an update of current evidence. Pain Physician 2013; 16(2 Suppl):SE229-60.
Manchikanti L, Falco FJ, Benyamin RM et al. An update of the systematic assessment of mechanical lumbar disc decompression with nucleoplasty. Pain Physician 2013; 16(2 Suppl):SE25-54.
. Percutaneous discectomy for treating herniated lumbar disc. ECRI Health Technology Information Service; 2013 December 27. [Hotline Response].
Vleeming A, Albert HB, Ostgaard HC, et al. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J. 2008; 17(6):794-819.
U.S. Food and Drug Administration (FDA) 510(k) Premarket Notification Database. SImmetry™ Sacroiliac Joint Fusion System Summary of Safety and Effectiveness. No. K110512External Site
. Rockville, MD: FDA. March 23, 2011.
Boswell MV, Trescot AM, Datta S et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 2007; 10(1):7-111.
North American Spine Society (NASS). NASS coverage policy recommendations: Percutaneous sacroiliac joint fusion. 2015; https://www.spine.org
Zheng Y, Gu M, Shi D, et al. Tomography-guided palisade sacroiliac joint radiofrequency neurotomy versus celecoxib for ankylosing spondylitis: a open-label, randomized, and controlled trial. Rheumatol Int. Sep 2014;34(9):1195-1202. PMID 24518967
Althoff CE, Bollow M, Feist E, et al. CT-guided corticosteroid injection of the sacroiliac joints: quality assurance and standardized prospective evaluation of long-term effectiveness over six months. Clin Rheumatol. Jun 2015;34(6):1079-1084. PMID 25896531
Hayes, Winifred S. Health Technology Brief. iFuse Implant System (SI-BONE Inc.) for sacroiliac joint fusion for treatment of low back pain. October 8, 2015. Available at: http://www.hayesinc.com
Miller, LE, Reckling, WC, and Block, JE. Analysis of postmarket complaints database for the iFuse SI Joint Fusion System(R): a minimally invasive treatment for degenerative sacroiliitis and sacroiliac joint disruption. Med Devices (Auckl). 2013;677-84. PubMed 23761982 [PMID]
Zaidi, HA, Montoure, AJ, and Dickman, CA. Surgical and clinical efficacy of sacroiliac joint fusion: a systematic review of the literature. J Neurosurg Spine. 2015;23(1):59-66. PubMed 25840040
Lingutla, KK, Pollock, R, and Ahuja, S. Sacroiliac joint fusion for low back pain: a systematic review and meta-analysis. Eur Spine J. 2016.PubMed 26957096
July 2016 - Annual Review, Policy Revised
October 2015 - Interim Review, Policy Revised
August 2015 - Annual Review, Policy Revised
September 2014 - Annual Review, Policy Revised
October 2013 - Annual Review, Policy Revised
November 2012 - Annual Review, Policy Renewed
November 2011 - Annual Review, Policy Renewed
October 2010 - Annual Review, Policy Renewed
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of technology assessment of new and emerging treatments, devices,
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*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.