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Cervical Radiculopathy Clinical Guidelines for Medical Necessity Review

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Cervical Radiculopathy Clinical Guidelines for Medical Necessity Review Cervical Radiculopathy Clinical Guidelines for Medical Necessity Review Version: 3.0 Effective Date: November 13, 2020 Cervical Radiculopathy (v3.0) © 2020 Cohere Health, Inc. All Rights Reserved. 2 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 Users​”. 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​: Specialty Area:​ Diseases of the musculoskeletal system and connection tissue (M00-M99) Care Path Group: ​Spine Care Path Name: ​Cervical Radiculopathy (M50, M54) Type:​ [​X​] Adult (18+ yo) | [_] Pediatric (0-17yo) Physician author: ​Mandy Armitage, MD (Sports Medicine) and ​Paul Johnson, MD (Orthopedic Spine Surgeon) Peer reviewed by: ​Adrian Thomas, MD (Orthopedic Spine Surgeon) Literature review current through​: June 19, 2020 Document last updated:​ November 13, 2020 Page 2 of 58 Cervical Radiculopathy (v3.0) © 2020 Cohere Health, Inc. All Rights Reserved. 3 Table of Contents Important Notices 2 Care Path Overview 7 Care Path Clinical Discussion 7 Key Information 8 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 12 Typical Physical Exam Findings 13 Typical Diagnostic Findings11 13 Care Path Services & Medical Necessity Criteria 14 Conservative Therapy 14 Service: Physical Therapy 14 General Guidelines 14 Medical Necessity Criteria 14 Indications 14 Non-Indications 14 Applicable CMS Medicare NCDs & LCDs 15 Site of Service Criteria 15 Procedure Codes (HCPCS/CPT) 15 Advanced Imaging 20 Service: Magnetic Resonance Imaging (MRI) 20 General Guidelines 20 Medical Necessity Criteria 20 Indications 20 Non-Indications 20 Applicable CMS Medicare NCDs & LCDs 21 Site of Service Criteria 21 Procedure Codes (HCPCS/CPT) 21 Service: Computed Tomography (CT) or Computed Tomography Myelogram (CTM) 22 General Guidelines 22 Medical Necessity Criteria 22 Page 3 of 58 Cervical Radiculopathy (v3.0) © 2020 Cohere Health, Inc. All Rights Reserved. 4 Indications 22 Non-Indications 22 Applicable CMS Medicare NCDs & LCDs 23 Site of Service Criteria 23 Procedure Codes (HCPCS/CPT) 23 Non-Surgical Management 24 Service: Epidural Steroid Injections/Selective Nerve Root Blocks 24 General Guidelines 24 Medical Necessity Criteria 24 Indications 24 Non-Indications 24 Applicable CMS Medicare NCDs & LCDs 25 Site of Service Criteria 25 Procedure Codes (HCPCS/CPT) 25 Surgical Management 28 Service: Anterior Cervical Discectomy with Fusion (ACDF) 28 General Guidelines 28 Medical Necessity Criteria 28 Indications 28 Non-Indications 29 Applicable CMS Medicare NCDs & LCDs 29 Site of Service Criteria 29 Procedure Codes (HCPCS/CPT) 29 Service: Posterior Cervical Decompression without Fusion: Laminectomy, Foraminotomy, or Laminoforaminotomy 31 General Guidelines 31 Medical Necessity Criteria 31 Indications 31 Non-Indications 32 Applicable CMS Medicare NCDs & LCDs 32 Site of Service Criteria 32 Procedure Codes (HCPCS/CPT) 32 Service: Posterior Decompression with Fusion 35 General Guidelines 35 Medical Necessity Criteria 35 Indications 35 Non-Indications 36 Applicable CMS Medicare NCDs & LCDs 36 Page 4 of 58 Cervical Radiculopathy (v3.0) © 2020 Cohere Health, Inc. All Rights Reserved. 5 Site of Service Criteria 36 Procedure Codes (HCPCS/CPT) 36 Service: Cervical Disc Replacement / Arthroplasty 37 General Guidelines 37 Medical Necessity Criteria 37 Indications 37 Non-Indications 38 Applicable CMS Medicare NCDs & LCDs 38 Site of Service Criteria 38 Procedure Codes (HCPCS/CPT) 38 Service: Anterior Cervical Discectomy (ACD) 40 General Guidelines 40 Medical Necessity Criteria 40 Indications 40 Non-Indications 41 Applicable CMS Medicare NCDs & LCDs 41 Site of Service Criteria 41 Procedure Codes (HCPCS/CPT) 41 Surgical Risk Factors 42 Postoperative Care 45 Service: Physical Therapy 45 General Guidelines 45 Medical Necessity Criteria 45 Indications 45 Non-Indications 45 Applicable CMS Medicare NCDs & LCDs 45 Site of Service Criteria 45 Procedure Codes (HCPCS/CPT) 45 Service: Home Health Care 50 General Guidelines 50 Medical Necessity Criteria 50 Indications 50 Non-Indications 50 Applicable CMS Medicare NCDs & LCDs 50 Site of Service Criteria 50 Procedure Codes (HCPCS/CPT) 50 Service: Inpatient Rehabilitation 52 General Guidelines 52 Page 5 of 58 Cervical Radiculopathy (v3.0) © 2020 Cohere Health, Inc. All Rights Reserved. 6 Medical Necessity Criteria 52 Indications 52 Non-Indications 52 Applicable CMS Medicare NCDs & LCDs 52 Site of Service Criteria 52 Procedure Codes (HCPCS/CPT) 53 Service: Skilled Nursing Facility 54 General Guidelines 54 Medical Necessity Criteria 54 Indications 54 Non-Indications 54 Applicable CMS Medicare NCDs & LCDs 54 Site of Service Criteria 54 Procedure Codes (HCPCS/CPT) 54 References 57 Page 6 of 58 Cervical Radiculopathy (v3.0) © 2020 Cohere Health, Inc. All Rights Reserved. 7 Care Path Overview Care Path Clinical Discussion Cervical radiculopathy ​is defined by the North American Spine Society as “pain in a radicular pattern in one or both upper extremities related to compression and/or irritation of one or more cervical nerve roots. Frequent signs and symptoms include varying degrees of sensory, motor and reflex changes as well as dysesthesias and paresthesias related to nerve root(s) 1​ without evidence of spinal cord dysfunction (myelopathy).”​ Compression may be due to herniated disc or, more commonly, cervical spondylosis. Most experts agree that the natural history of this condition is favorable, in that the majority of patients experience improvement in symptoms without 1​, ​2​ intervention.​ However, in the patients who do not experience self-resolution of symptoms or who have a complex spinal health history, further evaluation and intervention may be warranted. Advanced imaging may be appropriate in patients with a complicated initial 3 presentation, previous spinal surgery, or protracted or worsening symptoms.​ Physical therapy can help improve pain and function and therefore may be 4​, ​5​ utilized as conservative treatment.​ There is a paucity of high-quality studies (large numbers of patients, sufficient randomization, adequate follow-up, etc.) to fully evaluate the effectiveness of epidural steroid injections, but consideration of this procedure should be given for improvement of radicular 1​, ​6​ symptoms.​ Surgical treatment options include anterior cervical discectomy with or without fusion (ACDF), posterior decompression with or without fusion, and cervical disc replacement. Radiculopathy can be cause by compression 1 at multiple levels; therefore surgery may involve one or more levels.​ The information contained herein gives a general overview of the pathway of this specific diagnosis, beginning with 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 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. 1 Case-by-case treatment decisions are encouraged.​ Page 7 of 58 Cervical Radiculopathy (v3.0) © 2020 Cohere Health, Inc. All Rights Reserved. 8 Key Information ● Cervical radiculopathy is likely present at a primary care provider's office. ○ The average general practitioner is estimated to evaluate 7 9 people per week regarding neck or upper extremity pain.​ ○ The general practitioner must determine if the pain is with abnormal neurology and requires subsequent evaluation by a 7 spine subspecialist.​ ● Cervical radiculopathy is rare. ○ Incidence of 85 per 100,000 persons. ○ Men are slightly more affected than women. ○ Other risk factors include white race, cigarette smoking, and prior 10​, ​11 lumbar radiculopathy.​ ● The majority of patients with cervical radiculopathy are likely to improve over time with a focused, nonoperative therapy, such as physical 7​, ​11 therapy.​ ● Patients who have persistent symptoms or a progressive neurologic 11 deficit may be candidates for surgical intervention.​ Definitions ● Cervical radiculopathy ​is defined by the North American Spine
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