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Surgical Treatment for Spine Pain – Commercial Medical Policy

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Surgical Treatment for Spine Pain – Commercial Medical Policy UnitedHealthcare® Commercial Medical Policy Surgical Treatment for Spine Pain Policy Number: 2021T0547AA Effective Date: September 1, 2021 Instructions for Use Table of Contents Page Related Commercial Policies Coverage Rationale ....................................................................... 1 • Bone or Soft Tissue Healing and Fusion Documentation Requirements ...................................................... 2 Enhancement Products Definitions ...................................................................................... 3 • Discogenic Pain Treatment Applicable Codes .......................................................................... 6 • Epidural Steroid Injections for Spinal Pain Description of Services ............................................................... 13 • Facet Joint Injections for Spinal Pain Clinical Evidence ......................................................................... 14 U.S. Food and Drug Administration ........................................... 28 • Total Artificial Disc Replacement for the Spine • Vertebral Body Tethering for Scoliosis References ................................................................................... 28 Policy History/Revision Information ........................................... 32 Community Plan Policy Instructions for Use ..................................................................... 32 • Surgical Treatment for Spine Pain Coverage Rationale Spinal procedures for the treatment of spine pain are proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual® 2021: Apr. 2021 Release, CP: Procedures: o Decompression +/- Fusion, Thoracic o Fusion, Thoracic Spine July 2021 Release, CP: Procedures: o Decompression +/- Fusion, Cervical o Fusion, Cervical Spine o Decompression +/- Fusion, Lumbar o Fusion, Lumbar Spine Click here to view the InterQual® criteria. The following techniques for lumbar interbody fusion (LIF) are proven and medically necessary: Anterior LIF(ALIF) including lateral approaches, e.g., extreme lateral interbody fusion (XLIF®), Direct lateral interbody fusion (DLIF) Posterior LIF (PLIF), including transforaminal lumbar interbody fusion (TLIF) The following indications for a surgical spine procedure that is performed to alleviate symptoms or prevent clinical deterioration are considered proven and medically necessary if not addressed in the above criteria: Congenital or idiopathic deformity or bone disease Muscular dystrophy Laminectomy procedure to provide surgical exposure to treat lesions within the spinal canal The following spinal procedures are unproven and not medically necessary due to insufficient evidence of efficacy (this includes procedures that utilize interbody cages, screws, and pedicle screw fixation devices): Laparoscopic anterior lumbar interbody fusion (LALIF) Surgical Treatment for Spine Pain Page 1 of 33 UnitedHealthcare Commercial Medical Policy Effective 09/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. Transforaminal lumbar interbody fusion (TLIF) which utilizes only endoscopy visualization (such as a percutaneous incision with video visualization) Axial lumbar interbody fusion (AxiaLIF®) Interlaminar lumbar instrumented fusion (ILIF) utilizing an interspinous process fusion device Spinal decompression and interspinous process decompression systems for the treatment of lumbar spinal stenosis (e.g., Interspinous process decompression (IPD), Minimally invasive lumbar decompression (mild ®) Spinal stabilization systems o Stabilization systems for the treatment of degenerative spondylolisthesis o Total facet joint arthroplasty, including facetectomy, laminectomy, foraminotomy, vertebral column fixation o Percutaneous sacral augmentation (sacroplasty) with or without a balloon or bone cement for the treatment of back pain Stand-alone facet fusion without an accompanying decompressive procedures; this includes procedures performed with or without bone grafting and/or the use of posterior intrafacet implants such as fixation systems, facet screw systems or anti- migration dowels For information on vertebral body tethering, see the Medical policy titled Vertebral Body Tethering for Scoliosis. Documentation Requirements Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The documentation requirements outlined below are used to assess whether the member meets the clinical criteria for coverage but do not guarantee coverage of the service requested. CPT Codes* Required Clinical Information Surgical Treatment for Spine Pain 22100, 22101, 22102, Medical notes documenting the following, as applicable: 22110, 22112, 22114, Condition requiring procedure 22206, 22207, 22210, History and co-morbid medical condition(s) 22212, 22214, 22220, o Smoking history/status, including date of last smoking cessation 22224, 22532, 22533, Member’s symptoms, pain, location, and severity including functional impairment that is 22534, 22548, 22551, interfering with activities of daily living (meals, walking, getting dressed, driving) 22552, 22554, 22556, Failure of Conservative Therapy through lack of clinically significant improvement between 22558, 22585, 22586, at least two measurements, on a validated pain or function scale or quantifiable symptoms 22590, 22595, 22600, despite concurrent Conservative Therapies (see definition), if applicable 22610, 22612, 22614, Progressive deficits with clinically significant worsening based on at least two 22630, 22632, 22633, measurements over time, if applicable 22634, 22800, 22802, Surgical history, including date(s) and outcome(s) 22804, 22808, 22810, Progressive deficits with clinically significant worsening based on at least two 22812, 22818, 22819, measurements over time, if applicable 22830, 22840, 22841, Disabling Symptoms, if applicable 22842, 22843, 22844, Upon request, we may require the specific diagnostic image(s) that show the abnormality 22845, 22846, 22847, for which surgery is being requested, which may include MRI, CT scan, X-ray, and/or bone 22848, 22849, 22850, scan; consultation with requesting surgeon may be of benefit to select the optimal images 22852, 22853, 22854, o Note: When requested, diagnostic image(s) must be labeled with: 22855, 22859, 22899, . The date taken 63001, 63003, 63005, . Applicable case number obtained at time of notification, or member's name and ID 63011, 63012, 63015, number on the image(s) 63016, 63017, 63020, o Upon request, diagnostic imaging must be submitted via the external portal at 63030, 63035, 63040, www.uhcprovider.com/paan; faxes will not be accepted 63042, 63043, 63044, Diagnostic image(s) report(s) , including presence or absence of: 63045, 63046, 63047, o Segment (s) instability 63048, 63050, 63051, o Spinal cord compression 63055, 63056, 63057, o Disc herniation 63064, 63066, 63075, o Nerve root compression Surgical Treatment for Spine Pain Page 2 of 33 UnitedHealthcare Commercial Medical Policy Effective 09/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. CPT Codes* Required Clinical Information Surgical Treatment for Spine Pain 63076, 63077, 63078, o Quantification of subluxation, translation by flexion, angulation when appropriate 63081, 63082, 63085, o Discitis 63086, 63087, 63088, o Epidural abscess 63090, 63091, 63101, Physical exam, including neurologic exam, including degree and progression of curvature 63102, 63103, 63170, (for scoliosis), if applicable 63172, 63173, 63185, o Degree and progression of curvature (for scoliosis) 63190, 63191, 63194, o Quantification of relevant muscle strength 63195, 63196, 63197, Whether the surgery will be performed with direct visualization or only with endoscopic 63198, 63199, 63200, visualization 63250, 63251, 63252, Complete report(s) of diagnostic tests, including: 63265, 63266, 63267, o Results of biopsy(ies) 63268, 63270, 63271, o Results of bone aspirate 63272, 63275, 63277, Describe the surgical technique(s) planned [e.g., AxialLIF®, XLIF, ILIF, OLIF, LALIF, image- 63280, 63282, 63285, guided minimally invasive lumbar decompression (mild®), percutaneous endoscopic 63286, 63287, 63290, discectomy with or without laser, etc.] 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308. *For code descriptions, refer to the Applicable Codes section. Definitions Anterior Lumbar Spine Surgery: Performed by approaching the spine from the front of the body using a traditional front midline incision (i.e., through the abdominal musculature and retroperitoneal cavity) or by lateral approaches from the front side of the body (e.g., eXtreme lateral interbody fusion [XLIF]; direct interbody fusion [DLIF]; oblique interbody fusion [OLIF]). Arthrodesis: A surgical procedure to eliminate motion in a joint by providing a bony fusion. The procedure is used for several specific purposes: to relieve pain; to provide stability; to overcome postural deformity resulting from neurologic deficit; and to halt advancing disease. Axial Lumbar Interbody Fusion (AxiaLIF): Also called trans-sacral, transaxial or para-coccygeal interbody fusion is a minimally invasive technique used in L5-S1 (presacral) spinal fusions. The technique provides access to the spine along the long axis of the spine, as opposed to anterior, posterior or lateral approaches. The surgeon enters the back through a very small incision
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