Musculoskeletal Surgical Services: Spinal Decompression Surgery; Thoracic Decompression

Home , Corpectomy, Laminectomy, Spinal decompression

POLICY INITIATED: 06/30/2019 MOST RECENT REVIEW: 06/30/2019 POLICY # HH-5689

Overview Statement The purpose of these clinical guidelines is to assist healthcare professionals in selecting the medical service that may be appropriate and supported by evidence to improve patient outcomes. These clinical guidelines neither preempt clinical judgment of trained professionals nor advise anyone on how to practice medicine. The healthcare professionals are responsible for all clinical decisions based on their assessment. These clinical guidelines do not provide authorization, certification, explanation of benefits, or guarantee of payment, nor do they substitute for, or constitute, medical advice. Federal and State law, as well as member benefit contract language, including definitions and specific contract provisions/exclusions, take precedence over clinical guidelines and must be considered first when determining eligibility for coverage. All final determinations on coverage and payment are the responsibility of the health plan. Nothing contained within this document can be interpreted to mean otherwise. Medical information is constantly evolving, and HealthHelp reserves the right to review and update these clinical guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from HealthHelp. All trademarks, product names, logos, and brand names are the property of their respective owners and are used for purposes of information/illustration only.

Associated Procedure Codes: Procedure Code Description Code Laminectomy with exploration and/or decompression of spinal cord and/or cauda 63003 equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; thoracic Laminectomy with exploration and/or decompression of spinal cord and/or cauda 63016 equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; thoracic Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with 63046 decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; thoracic

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Transpedicular approach with decompression of spinal cord, equina and/or nerve 63055 root(s) (eg, herniated intervertebral disc), single segment; thoracic Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, 63064 herniated intervertebral disc), thoracic; single segment Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), 63077 including osteophytectomy; thoracic, single interspace Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic 63085 approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment Vertebral corpectomy (vertebral body resection), partial or complete, combined 63087 thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment Vertebral corpectomy (vertebral body resection), partial or complete, lateral 63101 extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic, single segment Laminectomy with rhizotomy; 1 or 2 segments 63185 Laminectomy with rhizotomy; more than 2 segments 63190 Laminectomy with section of spinal accessory nerve 63191 Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 stage; thoracic 63195 Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage; 63197 thoracic Laminectomy with cordotomy with section of both spinothalamic tracts, 2 stages 63199 within 14 days; thoracic Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; 63251 thoracic Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; 63252 thoracolumbar Vertebral corpectomy (vertebral body resection), partial or complete, for excision of 63301 intraspinal lesion, single segment; extradural, thoracic by transthoracic approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of 63302 intraspinal lesion, single segment; extradural, thoracic by thoracolumbar approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of 63305 intraspinal lesion, single segment; intradural, thoracic by transthoracic approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of 63306 intraspinal lesion, single segment; intradural, thoracic by thoracolumbar approach

Definition:

1. A cordotomy is a surgical procedure that is used to relieve pain by cutting the nerves of the spinal cord. Cutting selected nerves disables pain-conducting tracts in the spinal cord, effectively blocking pain sensation as well as temperature perception. The procedure is

typically performed on patients with severe pain from cancer and other non-curable

diseases. 8

Guideline:

. Additionally the use of thoracic spine laminectomy with cordotomy may be appropriate and supported by evidence to improve outcomes for patients when the patient’s medical record demonstrates any incurable condition affecting the thoracic spine, which has not responded to medication or intrathecal therapy. (7)

References 1. Anterior decompression and fusion for multiple thoracic disc herniation. K. OHNISHI, K. MIYAMOTO, Y. KANAMORI, H. KODAMA, H. HOSOE, K. SHIMIZU- The Journal of Bone and Joint Surgery. 2005;87-B:356-60. 2. Rahimi-Movaghar, Vafa. "Efficacy of surgical decompression in the setting of complete thoracic spinal cord injury." The journal of spinal cord medicine 28.5 (2005): 415-420. 3. Matsuyama, Yukihiro, et al. "Indirect posterior decompression with corrective fusion for ossification of the posterior longitudinal ligament of the thoracic spine: is it possible to predict the surgical results?." European Spine Journal 18.7 (2009): 943-948. 4. Chang, U. K., et al. "Surgical treatment for thoracic spinal stenosis." Spinal cord 39.7 (2001): 362. 5. Van Kleef, M., Stolker, R., Lataster, A., Geurts, J., Benzon, H., & Mekhail, N. (2010). 10. Thoracic Pain. Pain Practice, 10(4). 6. Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. Surgery versus conservative treatment for symptomatic lumbar spinal stenosis: a systematic review of randomized controlled trials. 2011. 7. Alireza Feizerfan, JHL Antrobus; Role of percutaneous cervical cordotomy in cancer pain management, Continuing Education in Anaesthesia Critical Care & Pain, Volume 14, Issue 1, 1 February 2014, Pages 23–26, https://doi.org/10.1093/bjaceaccp/mkt033. 8. https://www.spine-health.com/glossary/cordotomy