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Lumbar Radiculopathy with Or Without Disc Herniation Clinical Guidelines for Medical Necessity Review

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Lumbar Radiculopathy with Or Without Disc Herniation Clinical Guidelines for Medical Necessity Review Lumbar Radiculopathy with or without Disc Herniation Clinical Guidelines for Medical Necessity Review Version: 4.0 Effective Date: November 13, 2020 Lumbar Disc Herniation with Radiculopathy (v4.0) © 2020 Cohere Health, Inc. All Rights Reserved. Important Notices Notices & ​Disclaimers: GUIDELINES SOLELY FOR COHERE’S USE IN PERFORMING MEDICAL NECESSITY REVIEWS AND ARE NOT INTENDED TO INFORM OR ALTER CLINICAL DECISION MAKING OF END USERS. Cohere Health, Inc. (“​Cohere​”) has published these clinical guidelines to determine medical necessity of services (the “​Guidelines​”) for informational purposes only, and solely for use by Cohere’s authorized “​End User​s​”. These Guidelines (and any attachments or linked third party content) are not intended to be a substitute for medical advice, diagnosis, or treatment directed by an appropriately licensed healthcare professional. These Guidelines are not in any way intended to support clinical decision making of any kind; their sole purpose and intended use is to summarize certain criteria Cohere may use when reviewing the medical necessity of any service requests submitted to Cohere by End Users. Always seek the advice of a qualified healthcare professional regarding any medical questions, treatment decisions, or other clinical guidance.​ ​The Guidelines, including any attachments or linked content, are subject to change at any time without notice. ©2020 Cohere Health, Inc. All Rights Reserved. Other ​Notices: CPT copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Guideline​ ​Information​: Disease Area:​ Diseases of the musculoskeletal system and connective tissue (M00-M99) CarePath Group: ​Spine CarePath Name: ​Lumbar Radiculopathy with or without Disc Herniation (M51, M54) Type:​ [​X​] Adult (18+ yo) | [_] Pediatric (0-17yo) Physician author: ​Mandy Armitage, MD (Sports Medicine) Peer reviewed by: ​Paul Johnson, MD (Orthopedic Spine Surgeon) Literature review current through​: May 8, 2020 Document last updated:​ November 13, 2020 Page 2 of 61 Lumbar Disc Herniation with Radiculopathy (v4.0) © 2020 Cohere Health, Inc. All Rights Reserved. Table of Contents Important Notices 2 Care Path Overview 7 Care Path Clinical Discussion 7 Key Information 7 Definitions 8 Care Path Diagnostic Criteria 10 Disease Classification 10 ICD-10 Codes Associated with Classification 10 Presentation and Etiology 12 Causes and Risk Factors 12 Clinical Presentation 1,7 12 Typical Physical Exam Findings 1 12 Typical Diagnostic Findings 12 Care Path Services & Medical Necessity Criteria 13 Conservative Therapy 13 Service: Anti-Inflammatories, Acetaminophen, Gabapentin, or Muscle Relaxers 13 General Guidelines 13 Medical Necessity Criteria 13 Indications 13 Non-Indications 13 Applicable CMS Medicare NCDs & LCDs 13 Site of Service Criteria 13 Procedure Codes (HCPCS/CPT) 13 Service: Physical Therapy 14 General Guidelines 14 Medical Necessity Criteria 14 Indications 14 Non-Indications 14 Applicable CMS Medicare NCDs & LCDs 14 Site of Service Criteria 15 Procedure Codes (HCPCS/CPT) 15 Diagnostics 20 Service: Radiography (plain x-ray) 20 General Guidelines 20 Page 3 of 61 Lumbar Disc Herniation with Radiculopathy (v4.0) © 2020 Cohere Health, Inc. All Rights Reserved. Medical Necessity Criteria 20 Indications 20 Non-Indications 20 Applicable CMS Medicare NCDs & LCDs 20 Site of Service Criteria 20 Procedure Codes (HCPCS/CPT) 21 Advanced Imaging 22 Service: Magnetic Resonance Imaging (MRI) 22 General Guidelines 22 Medical Necessity Criteria 22 Indications 22 Non-Indications 23 Applicable CMS Medicare NCDs & LCDs 23 Site of Service Criteria 23 Procedure Codes (HCPCS/CPT) 23 Service: Computed Tomography (CT) or CT Myelogram (CTM) 24 General Guidelines 24 Medical Necessity Criteria 24 Indications 24 Non-Indications 24 Applicable CMS Medicare NCDs & LCDs 24 Site of Service Criteria 25 Procedure Codes (HCPCS/CPT) 25 Non-Surgical Management 26 Service: Epidural Steroid Injections 26 General Guidelines 26 Medical Necessity Criteria 26 Indications 26 Non-Indications 13 27 Site of Service Criteria 27 Procedure Codes (HCPCS/CPT) 27 Surgical Management 29 Service: Lumbar Discectomy 29 General Guidelines 29 Medical Necessity Criteria 29 Indications 29 Non-Indications 29 Page 4 of 61 Lumbar Disc Herniation with Radiculopathy (v4.0) © 2020 Cohere Health, Inc. All Rights Reserved. Applicable CMS Medicare NCDs & LCDs 30 Site of Service Criteria 30 Procedure Codes (HCPCS/CPT) 30 Service: Lumbar Decompression Without Fusion 33 General Guidelines 33 Medical Necessity Criteria 33 Indications 33 Non-Indications 34 Applicable CMS Medicare NCDs & LCDs 34 Site of Service Criteria 34 Procedure Codes (HCPCS/CPT) 34 Service: Lumbar decompression with fusion 38 General Guidelines 38 Medical Necessity Criteria 38 Indications 38 Applicable CMS Medicare NCDs & LCDs 39 Site of Service Criteria 39 Procedure Codes (HCPCS/CPT) 39 Surgical Risk Factors 43 Post-Operative Care 46 Service: Physical Therapy 46 General Guidelines 46 Medical Necessity Criteria 46 Indications 46 Non-Indications 46 Applicable CMS Medicare NCDs & LCDs 46 Site of Service Criteria 46 Procedure Codes (HCPCS/CPT) 46 Service: Home Health Care 51 General Guidelines 51 Medical Necessity Criteria 51 Indications 51 Non-Indications 51 Applicable CMS Medicare NCDs & LCDs 51 Site of Service Criteria 51 Procedure Codes (HCPCS/CPT) 52 Service: Rehabilitation - Inpatient 53 Page 5 of 61 Lumbar Disc Herniation with Radiculopathy (v4.0) © 2020 Cohere Health, Inc. All Rights Reserved. General Guidelines 53 Medical Necessity Criteria 53 Indications 53 Non-Indications 53 Applicable CMS Medicare NCDs & LCDs 53 Site of Service Criteria 53 Procedure Codes (HCPCS/CPT) 53 Service: Skilled Nursing Facility 56 General Guidelines 56 Medical Necessity Criteria 56 Indications 56 Non-Indications 56 Applicable CMS Medicare NCDs & LCDs 56 Site of Service Criteria 56 Procedure Codes (HCPCS/CPT) 56 Other Services 59 Service: Bracing 59 General Guidelines 59 Medical Necessity Criteria 59 Indications 59 Non-Indications 59 Applicable CMS Medicare NCDs & LCDs 59 Site of Service Criteria 59 Procedure Codes (HCPCS/CPT) 59 References 59 Page 6 of 61 Lumbar Disc Herniation with Radiculopathy (v4.0) © 2020 Cohere Health, Inc. All Rights Reserved. Care Path Overview Care Path Clinical Discussion Lumbar disc herniation with radiculopathy​ is defined by the North American Spine Society as “localized displacement of disc material beyond the normal margins of the intervertebral disc space resulting in pain, weakness or 1​ numbness in a myotomal or dermatomal distribution​.​”​ The information contained herein gives a general overview of the pathway of this specific diagnosis, beginning with an initial presentation, recommended assessments, and treatment options as supported by the medical literature and existing guidelines. It should be noted that the care of patients with spinal health problems is complex. The information below is meant to support clinical decision making for lumbar disc herniation with radiculopathy in adult patients. It is not necessarily applicable to every case, as the entire clinical picture (including comorbidities, spinal health history, etc.) should be considered. Case-by-case treatment decisions are encouraged. Key Information ➢ Lumbosacral radiculopathy is a common complaint that patients present at their annual doctor’s visit with their primary care provider and is 11 subsequently evaluated by a spine surgeon.​ ➢ Lumbar radiculopathy has a prevalence of 3%-5% of the population. Risk factors include placing repetitive or excessive load on the spine, which makes patients involved in heavy manual labor, service in the military, or contact sports more likely to develop the condition. Symptoms typically 11​, ​12 start when patients are in their 40s-50s and are more common in men.​ ➢ The vast majority of cases are benign and will resolve on their own and the first line of treatment involves conservative management such as over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) and 11​, ​12 physical therapy.​ ➢ Epidural steroid injections can be considered a reasonable means to treat symptoms, but there has not been evidence to prove a long-term outcome. If non-surgical and conservative management fails and with refractory cases, percutaneous discectomy and lumbar fusion may be 13 performed.​ Page 7 of 61 Lumbar Disc Herniation with Radiculopathy (v4.0) © 2020 Cohere Health, Inc. All Rights Reserved. Definitions ● Lumbar disc herniation with radiculopathy​ is defined by the North American Spine Society as “localized displacement of disc material beyond the normal margins of the intervertebral disc space resulting in pain, weakness or numbness in a myotomal or dermatomal 1 distribution.”​ ● Dermatomes​ are nerve fibers allowing for the sensation of touch or feeling pain to a corresponding sensory sector of the skin. ● Myotomes ​are the muscles served by the spinal root. ● Straight leg raise test ​is a neurological maneuver in which an examiner gently raises a supine patient’s leg by flexing the hip with the knee in full extension. A positive result occurs when the patient experiences pain along the lower limb in the same distribution of the lower radicular nerve roots, or when pain is elicited by lower limb flexion in a >45° 18 angle.​ ● Contralateral straight leg raise or crossed straight leg raise (crossed Lasegue) ​is when the examiner raises the supine patient’s unaffected leg. A positive result occurs if there
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