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Home , Discectomy, Facetectomy, Foraminotomy, Lumbar disc disease, Rhizotomy

Minimally invasive and laser spine procedures These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative Process

Prior authorization is required when requested for the following non-covered radiofrequency ablation procedures:

1. Laser or endoscopic facet ablation / denervation /. For radiofrequency ablation for treatment of facet-mediated or sacroiliac (64625, 64633, 64634, 64635, 64636), see Radiofrequency ablative (RFA) denervation procedures for chronic facet-mediated neck, back and sacroiliac joint pain policy, link in related content.

Prior authorization is not required for microdisectomy, also known as percutaneous manual nucleotomy.

Prior authorization is not applicable for minimally invasive spine procedures and laser spine procedures because these services are considered investigational/experimental. The provider and facility will be liable for payment unless: 1. The provider notifies the member that a specific service has been determined by HealthPartners to be investigational/experimental; and 2. The member signs a waiver agreeing to pay for the specific non-covered service being rendered; and 3. The claim has been billed with a GA modifier indicating such. If the member has signed a waiver agreeing to pay for the specific service then the member will be liable for payment.

Coverage

• Microdiscectomy, also known as percutaneous manual nucleotomy, is generally covered subject to the indications listed below and per your plan documents. • Minimally invasive back procedures, including but not limited to those listed below, are considered investigational/experimental and therefore not covered.

Procedures that are covered

Microdiscectomy, also known as percutaneous manual nucleotomy, (63030).

Procedures that are not covered

The following procedures are considered investigational and not covered because the reliable evidence does not allow conclusions concerning safety, effectiveness, or effect on health outcomes. 1. Laser spine procedures, including but not limited to: A. Laser , also known as laser-assisted discectomy, laser disc decompression or laser-assisted disc decompression (LADD) (62287) B. Percutaneous laser discectomy (62287) C. Laparoscopic laser discectomy D. Endoscopic laser foraminoplasty E. Endoscopic laser F. Endoscopic laser G. Laser H. Laser facet ablation / denervation /rhizotomy Clinical studies have not shown a clinically significant benefit of use of laser over any other method of tissue resection in spinal . No additional benefit will be provided for the use of a laser in spinal surgery. 2. Percutaneous and endoscopic laminectomy and disc decompression procedures of the cervical, thoracic, or lumbar spine including but not limited to: A. Percutaneous endoscopic discectomy with or without laser (PELD) (also known as arthroscopic microdiscectomy or Yeung Endoscopic Spinal Surgery System (Y.E.S.S.) B. APLD (Automated percutaneous lumbar discectomy) (62287) C. Endoscopic procedures using the DiscFX™ System D. Minimally invasive percutaneous decompression – “mild® procedure. (0274T, 0275T) 3. Thermal intradiscal procedures (TIPs) including but not limited to:

Page 1 of 6 A. Intradiscal electrothermal therapy (IDET) / Intradiscal electrothermal annuloplasty (IEA)/ Intradiscal thermal annuloplasty (IDTA) (22526, 22527) B. Nucleoplasty/decompression nucleoplasty/percutaneous (or plasma) disc decompression (PDD) (e.g., SpineWand™, Coblation therapy) C. Transdiscal biacuplasty/ Intradiscal biacuplasty (IDB)/cooled radiofrequency ablation (RFA) (22526, 22527) D. Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) (22526, 22527) 4. Intradiscal steroid injection 5. Devices for annulus repair (i.e. X-close disc annual repair technology (DART) 6. Epidurolysis / percutaneous epidural adhesiolysis (62263, 62264) 7. Endoscopic radiofrequency denervation/rhizotomy 8. Intraosseous radiofrequency ablation of the basivertebral (e.g., Intracept®) (C9752 C9753) 9. Interspinous process distraction, also known as interspinous decompression, and interlaminar dynamic stabilization devices (22867, 22868, 22869, 22870, C1821) (including but not limited to Coflex® Interlaminar Technology Implant, Coflex interlaminar Stabilization device, Superion® Interprocess spacer, Aperius™ PercLID™ system). 10. Isolated facet fusion (eg Tru Fuse) (0219T, 0220T, 0221T, 0222T)

Definitions

Discectomy is the partial or complete removal of an . Intervertebral discs are made of rubbery tissue and are located between the vertebrae () of the spinal column

Foraminectomy and foraminotomy are performed to expand the openings between (the vertebral openings (foramen) by removing some bone and other tissue. The nerve roots exit the through these openings. A foraminectomy or foraminotomy is often performed on an individual who has arthritis, a l disc herniation (bulging disc tissue), or spinal stenosis (narrowing of spaces within the spine). The term foraminectomy is used to refer to a procedure that removes a large amount of bone and tissue, and foraminotomy when a smaller amount is removed.

Intradiscal steroid injection is an injection of steroid medication into the space between the vertebrae (bones of the spine).

Intradiscal thermal procedures are techniques that use a probe-like instrument to generate heat by using radiofrequency energy (radio waves). The goal is to relieve pain and repair abnormal structures within the affected disc. • IDET (intradiscal electrothermal therapy (also known as intradiscal electrothermal annuloplasty (IDTA) or IEA) involves the insertion of a probe into a spinal disc. The tissue is heated by the probe, which causes it to shrink and scar, with the goal of relieving the pain. • Cooled radiofrequency ablation (RFA) / Transdiscal biacuplasty/Intradiscal biacuplasty is similar to IDET, utilizing two water-cooled electrodes to deliver radiofrequency energy into the disc, with the goal of relieving pain. • Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) applies radiofrequency (radio wave) energy directly to the center of the disc using a catheter (tube) containing a heated coil.

Intraosseous RFA of the basivertebral nerve for treatment of low (e.g. Intracept ® procedure) uses radiofrequency (radio wave) energy to destroy part of the basivertebral nerve (BVN), with the goal of interrupting the nerve pathway that may be causing chronic back pain. The basivertebral are found within foramen (openings) of the bones in the spine. A probe-like instrument is used to apply radiofrequency energy to the nerve.

Interspinous process distraction, (also known as interspinous process decompression) and Interspinous stabilization are minimally invasive procedures designed to treat the symptoms of (narrowing of spinal canal). Interspinous process decompression implants (may be called spacers) are placed at one or two levels of the lumbar spine, with the goal of creating more space for the spinal cord and nerves. They are not permanently affixed to the bone or ligaments. Interspinous stabilization devices are utilized as an adjunct to decompression surgery and function to provide additional stability in the place of a fusion.

Lumbar disc herniation is caused when the outer casing of the disc bursts and some of the rubbery disc material seeps out, sometimes causing pain. Disc herniation is the most common cause of nerve pain felt going down the back and leg, sometimes with leg numbness or weakness ().

Microdiscectomy is a discectomy (partial or complete removal of an intervertebral disc) done with a very small incision (cut), usually about 1 inch long using manual instruments and technique.

Page 2 of 6 Minimally invasive describes techniques that limit the size and number of incisions (cuts) that the physician needs to make to complete a surgery or procedure.

Minimally invasive lumbar decompression (mild®) - A minimally invasive surgery that treats lumbar spinal stenosis (narrowing of spinal canal) using a small opening in the skin. Instruments are placed through the skin, increasing the size of the spinal canal, to provide more space fora compressed nerve. The mild® procedure is an image-guided surgery—the spine is not directly viewed by the surgeon.Rather, the procedure is guided by fluoroscopy, a method of observing body structures on a screen. May also be referred to as percutaneous imaged- guided lumbar decompression (PILD).

Percutaneous refers to the insertion of a tube catheter, or endoscope through the skin. An endoscope is a flexible instrument that can be used to view body tissues and also remove tissue or repair structures. It looks like a large flexible needle and makes a very small incision (cut). Many percutaneous procedures that include the removal of disc material are performed by inserting t instruments through an endoscope.

Percutaneous intradiscal procedures are minimally invasive techniques performed on discs through a small opening in the skin with the goal of relieving , radiculopathy (leg numbness or weakness) and (buttock and leg nerve pain). The procedure removes part of the nucleus pulposus (gel like disc material) relieving pressure on nerve roots. Percutaneous intradiscal procedures may surgically remove disc material, destroy disc material or alter the disc through the application of heat. • APLD (Automated percutaneous lumbar discectomy) involves a probe inserted through a cannula (tube) which is used to cut and remove disc material. • Disc nucleoplasty (also known as percutaneous radiofrequency thermomodulation, percutaneous plasma discectomy or plasma disc decompression [PDD]) is a minimally invasive procedure to treat individuals with low back and leg pain caused by herniated discs. The procedure may utilize a device called the ArthroCare SpineWand®, The SpineWand® is designed to relieve pressure on spinal nerves adjacent to the disc by removing disc material. This procedure uses a technology referred to as Coblation®, in which the SpineWand® applies an electric current through the tip of the wand. • Laser Discectomy is a percutaneous procedure which uses a laser device to shrink the enlarged disc that is causing the low back pain. There are several laser discectomy devices, including LASE® (laser assisted spinal endoscopy), LADD (laser assisted disc decompression), and others. • Percutaneous manual nucleotomy refers to the technique involving the use of specialized tools to remove the disc through a cannula (tube).

Codes If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.

CPT codes that are covered services: Lumbar microdiscectomy/Percutaneous manual nucleotomy Codes Description 63030 Laminotomy (hemilaminectomy), with decompression of (s), including partial , foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar

CPT codes that are not covered services: Laser discectomy, also known as laser-assisted discectomy, laser disc decompression or laser-assisted disc decompression, Codes Description 22526 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level

22527 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure)

22867 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level 22868 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure) 22869 Insertion of interlaminar/interspinous process stabilization/distraction device, without open

Page 3 of 6 decompression or fusion, including image guidance when performed, lumbar; single level 22870 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level 62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar 62380 Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar C2614 Probe, percutaneous lumbar discectomy 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 0219T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical 0220T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic 0221T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar 0222T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; each additional vertebral segment (List separately in addition to code for primary procedure) 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 C1821 Interspinous process distraction device (implantable) C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure) 22899 Unlisted procedure, spine 64999 Unlisted procedure, nervous system

CPT codes that require prior authorization: Laser facet ablation / denervation /rhizotomy See policy titled: Radiofrequency ablative denervation (RFA) procedures for chronic facet-mediated neck back pain and sacroiliac joint pain Codes Description 64625 Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint 64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) 64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint 64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Page 4 of 6 Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

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ECRI Institute. (2019). Disc-FX system (Elliquence, LLC) for Treating . Plymouth Meeting, PA: ECRI Institute. 7. *ECRI Institute. (2011). Laser Discectomy for the Treatment of Herniated Lumbar Discs. Plymouth Meeting, PA: ECRI Institute. 8. ECRI Institute. (2012). Lateral and Axial Lumbar Interbody Fusion Systems for Minimally Invasive Surgery. Plymouth Meeting, PA: ECRI Institute. 9. ECRI Institute. (2018). mild ®Device Kit (Vertos Medical, Inc) for Treating Lumbar Spinal Stenosis Plymouth Meeting, PA: ECRI Institute. 10. ECRI Institute. (2011). Minimally Invasive Lumbar Decompression for Treating Degenerative Lumbar Disease. Plymouth Meeting, PA: ECRI Institute. 11. ECRI Institute (2016). Percutaneous Laser Disc Decompression for Treating Herniated Lumbar Discs. Plymouth Meeting (PA): ECRI Institute. 12. ECRI Institute. (2012). Racz Procedure for Treating Chronic Low-back Pain. Plymouth Meeting, PA: ECRI Institute. 13. ECRI Institute. (2012). Radiofrequency Denervation for Treating Chronic Low-Back Pain. Plymouth Meeting, PA: ECRI Institute 14. *ECRI Institute. Surgical Devices for Repairing Annulus Fibrosus after Discectomy. Plymouth Meeting (PA): ECRI Institute; 2015 Sep 15. (Custom Rapid Review). 15. Finch, P. M., Price, L. M., & Drummond, P. D. (2005). Radiofrequency heating of painful annular disruptions: one-year outcomes. Clinical Spine Surgery, 18(1), 6-13. 16. Gibson JNA, Grant IC, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD001350. 17. Hayes, Inc. Hayes Health Technology Brief. Coflex Intralaminar Stabilization Device (Paradigm Spine LLC) for Treatment of Lumbar Spinal Stenosis Lansdale, PA: Hayes, Inc.; September 2018. Reviewed October 2020 18. Hayes, Inc. Evidence Analysis Research Brief. Intracept Procedure (Relievant Medsystems, Inc) For Treatment of Low Back Pain. Lansdale, PA: Hayes, Inc.; April 2020 19. Hayes, Inc. 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Approved Medical Director Committee 4/8/05; Revised 10/31/07, 7/14/10, 3/15/13, 5/23/13, 7/27/17, 11/15/17; 4/28/20 Annual Review 7/1/06; 10/31/07, 8/1/08, 9/9/09, 5/14/10, 7/14/10, 4/2011, 4/2012, 3/15/13, 5/2013, 3/2014, 3/2015, 3/2016, 3/2017, 3/2018, 3/2019, 3/2020, 3/2021

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