Applies To: Benefit Application Policy Criteria
PROVIDENCE HEALTH PLANS AND Back: Cervical and Thoracic Spine PROVIDENCE HEALTH ASSURANCE MEDICAL Surgery POLICY
Effective Date: 7/1/2018 Section: SUR Policy No: 120 Technology Assessment Committee Approved Date: 1/14; 1/15; 5/15 Medical Policy Committee Approved Date: 11/06; 9/07; 7/1/18 7/09; 1/11; 12/11; 2/12; 8/13; 3/16; 6/18 Medical Officer Date
See Policy CPT CODE section below for any prior authorization requirements
APPLIES TO:
All lines of business
BENEFIT APPLICATION
Medicaid Members
Oregon: Services requested for Oregon Health Plan (OHP) members follow the OHP Prioritized List and Oregon Administrative Rules (OARs) for coverage determinations.
For other lines of business, refer to the Policy Criteria section below:
POLICY CRITERIA A minimum 6 week course of conservative care is recommended prior to surgical consideration unless there are rapidly progressive symptoms or major motor dysfunctions. Immediate surgery may be necessary for fractures or tumors. Conservative care may include:
NSAIDS Physical Therapy Cervical Traction Corticosteroids Analgesics
Laminectomy-Disectomy Radicular pain, weakness or numbness that corresponds to physical findings and to spinal pathology found with imaging. Neck or back pain alone in a degenerative spine is not a consideration for surgery; however, extreme cases will be considered on a case by case basis when all conservative measures have failed and there is significant disability from the pain. Failure of 6 weeks of conservative care unless there is intolerable radicular pain, significant motor dysfunction, or progressive neurologic changes.
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Spinal Fusion Documented instability or expected instability from the decompression. Anterior approaches usually require interbody fusion. The proposed fusion procedures (especially if complex with multiple levels, bone grafts, plates, etc) must be reasonable and appropriate for the clinical condition.
Percutaneous and Endoscopic Laminectomy Disc Decompressions for Disc Herniation are not covered. There is inadequate evidence to justify its use and Hayes ranks this as a C.
CPT CODES
All Lines of Business Prior Authorization Required 22100 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical 22101 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracic 22103 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; each additional segment (List separately in addition to code for primary procedure) 22532 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic 22534 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure) 22548 Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process 22551 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 22552 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure) 22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 22556 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic 22590 Arthrodesis, posterior technique, craniocervical (occiput-C2) 22595 Arthrodesis, posterior technique, atlas-axis (C1-C2) 22600 Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment 22610 Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral
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transverse technique, when performed) 22614 Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) 22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure) 22841 Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) 22842 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure) 22843 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure) 22844 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure) 22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure) 22846 Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) 22847 Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure) 63001 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical 63003 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; thoracic 63012 Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) 63015 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; cervical 63016 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; thoracic 63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical 63035 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary
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procedure) 63040 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical 63043 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (List separately in addition to code for primary procedure) 63045 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical 63046 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; thoracic 63048 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) 63050 Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments 63051 Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices [eg, wire, suture, mini-plates], when performed) 63055 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic 63057 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure) 63064 Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; single segment 63066 Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; each additional segment (List separately in addition to code for primary procedure) 63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace 63076 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure) 63077 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, single interspace 63078 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, each additional interspace (List separately in addition to code for primary procedure)
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63081 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment 63082 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for primary procedure) 63085 Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment 63086 Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, each additional segment (List separately in addition to code for primary procedure) 63087 Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment 63101 Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic, single segment 63103 Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic or lumbar, each additional segment (List separately in addition to code for primary procedure) 63170 Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar 63180 Laminectomy and section of dentate ligaments, with or without dural graft, cervical; 1 or 2 segments 63182 Laminectomy and section of dentate ligaments, with or without dural graft, cervical; more than 2 segments 63185 Laminectomy with rhizotomy; 1 or 2 segments 63190 Laminectomy with rhizotomy; more than 2 segments 63191 Laminectomy with section of spinal accessory nerve 63194 Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 stage; cervical 63195 Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 stage; thoracic 63196 Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage; cervical 63197 Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage; thoracic 63198 Laminectomy with cordotomy with section of both spinothalamic tracts, 2 stages within 14 days; cervical 63199 Laminectomy with cordotomy with section of both spinothalamic tracts, 2 stages within 14 days; thoracic 63265 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical 63266 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic 63270 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical 63271 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; thoracic Page 5 of 8 SUR120 PROVIDENCE HEALTH PLANS AND Back: Cervical and Thoracic Spine PROVIDENCE HEALTH ASSURANCE MEDICAL Surgery POLICY
63275 Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical 63276 Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, thoracic 63280 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, cervical 63281 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, thoracic 63285 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical 63286 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracic 63287 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracolumbar 63300 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, cervical 63301 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by transthoracic approach 63302 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by thoracolumbar approach 63304 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, cervical 63305 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by transthoracic approach 63306 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by thoracolumbar approach 63308 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; each additional segment (List separately in addition to codes for single segment) No Prior Authorization Required 63088 Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; each additional segment (List separately in addition to code for primary procedure)
DESCRIPTION
“Most patients with axial neck pain and cervical radiculopathy can be managed conservatively. Surgical intervention for radiculopathy is considered only when conservative management has failed unless the neurologic deficits are very significant. In cases of myelopathy, surgery may be considered earlier, but if the myelopathy is mild, conservative treatment and close observation are still appropriate. For patients with axial neck pain, surgery is generally not considered except for rare cases caused by single-or two-level degenerative disk disease with severe and unrelenting pain.”
Cervical and thoracic spinal surgery is indicated for a variety of conditions including; Page 6 of 8 SUR120 PROVIDENCE HEALTH PLANS AND Back: Cervical and Thoracic Spine PROVIDENCE HEALTH ASSURANCE MEDICAL Surgery POLICY
Disc herniation Spinal instability Neural impingement Trauma Progressive and significant deformity such as scoliosis or kyphosis Tumors
INSTRUCTIONS FOR USE
Providence Health Plan (PHP) and Providence Health Assurance (PHA) Medical Policies serve as guidance for the administration of plan benefits. Medical policies do not constitute medical advice nor a guarantee of coverage. PHP and PHA Medical Policies are reviewed annually and are based upon published, peer-reviewed scientific evidence and evidence-based clinical practice guidelines that are available as of the last policy update. PHP and PHA reserve the right to determine the application of Medical Policies and make revisions to its Medical Policies at any time. Providers will be given at least 60-days’ notice of policy changes that are restrictive in nature.
The scope and availability of all plan benefits are determined in accordance with the applicable coverage agreement. Any conflict or variance between the terms of the coverage agreement and PHP and PHA Medical Policy will be resolved in favor of the coverage agreement.
REGULATORY STATUS
Mental Health Parity Statement
Coverage decisions are made on the basis of individualized determinations of medical necessity and the experimental or investigational character of the treatment in the individual case.
REFERENCES
ECRI: Custom Rapid Reviews - Guidance Percutaneous Discectomy for Treating Herniated Lumbar Disc Updated 8/22/2015 Published 12/27/2013
PubMed: 1. J Neurosurg Spine. 2016 Jan 22:1-12. [Epub ahead of print] Subsequent surgery rates after cervical total disc replacement using a Mobi-C Cervical Disc Prosthesis versus anterior cervical discectomy and fusion: a prospective randomized clinical trial with 5-year follow- up. Jackson RJ1, Davis RJ2, Hoffman GA3, Bae HW4, Hisey MS5, Kim KD6, Gaede SE7, Nunley PD8.
2. J Neurosurg Spine. 2015 Sep;23(3):280-9. doi: 10.3171/2014.12.SPINE14545. Epub 2015 Jun 19.
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Two-level corpectomy versus three-level discectomy for cervical spondylotic myelopathy: a comparison of perioperative, radiographic, and clinical outcomes. Lau D1, Chou D1, Mummaneni PV1.
3. Eur Spine J. 2015 Apr;24 Suppl 3:287-313. doi: 10.1007/s00586-015-3886-1. Epub 2015 Apr 8. MIS lateral spine surgery: a systematic literature review of complications, outcomes, and economics. Lehmen JA1, Gerber EJ. 4. Int J Surg. 2015 Mar;15:68-73. doi: 10.1016/j.ijsu.2014.12.029. Epub 2015 Jan 9. A cost-minimization analysis in minimally invasive spine surgery using a national cost scale method. Maillard N1, Buffenoir-Billet K2, Hamel O2, Lefranc B3, Sellal O1, Surer N4, Bord E2, Grimandi G1, Clouet J5.
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