Musculoskeletal Surgical Services: Spinal Decompression Surgery; Lumbar Laminectomy for Tethered Spinal Cord POLICY INITIATED: 06/30/2019 MOST RECENT REVIEW: 06/30/2019 POLICY # HH-5690 Overview Statement The purpose of these clinical guidelines is to assist healthcare professionals in selecting the medical service that may be appropriate and supported by evidence to improve patient outcomes. These clinical guidelines neither preempt clinical judgment of trained professionals nor advise anyone on how to practice medicine. The healthcare professionals are responsible for all clinical decisions based on their assessment. These clinical guidelines do not provide authorization, certification, explanation of benefits, or guarantee of payment, nor do they substitute for, or constitute, medical advice. Federal and State law, as well as member benefit contract language, including definitions and specific contract provisions/exclusions, take precedence over clinical guidelines and must be considered first when determining eligibility for coverage. All final determinations on coverage and payment are the responsibility of the health plan. Nothing contained within this document can be interpreted to mean otherwise. Medical information is constantly evolving, and HealthHelp reserves the right to review and update these clinical guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from HealthHelp. All trademarks, product names, logos, and brand names are the property of their respective owners and are used for purposes of information/illustration only. Associated Procedure Codes: Procedure Code Description Code Laminectomy with exploration and/or decompression of spinal cord and/or cauda 63005 equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis Laminectomy with exploration and/or decompression of spinal cord and/or cauda 63011 equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; sacral Laminectomy with removal of abnormal facets and/or pars inter-articularis with 63012 decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) Clinical Guidelines for Medical Necessity Review of Musculoskeletal Surgical Services. http://www.healthhelp.com | © 2019 HealthHelp. All rights reserved. 16945 Northchase Dr #1300, Houston, TX 77060 (281) 447‐7000 Laminectomy with exploration and/or decompression of spinal cord and/or cauda 63017 equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including 63030 partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including 63042 partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with 63047 decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar Transpedicular approach with decompression of spinal cord, equina and/or nerve 63056 root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc) Vertebral corpectomy (vertebral body resection), partial or complete, combined 63087 thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal 63090 or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment Vertebral corpectomy (vertebral body resection), partial or complete, lateral 63102 extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); lumbar, single segment Laminectomy with rhizotomy; 1 or 2 segments 63185 Laminectomy with rhizotomy; more than 2 segments 63190 Laminectomy with section of spinal accessory nerve 63191 Laminectomy, with release of tethered spinal cord, lumbar 63200 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of 63303 intraspinal lesion, single segment; extradural, lumbar or sacral by transperitoneal or retroperitoneal approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of 63307 intraspinal lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal approach Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of 0275T 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 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of 63300 intraspinal lesion, single segment; extradural, cervical Clinical Guidelines for Medical Necessity Review of Musculoskeletal Surgical Services. http://www.healthhelp.com | © 2019 HealthHelp. All rights reserved. 16945 Northchase Dr #1300, Houston, TX 77060 (281) 447‐7000 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of 63304 intraspinal lesion, single segment; intradural, cervical Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of 0275T 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 Definition: 1. The most common treatment for tethered spinal cord is a lumbar laminectomy to release the tethered cord. The neurological surgeon makes an incision in the lower back to expose the site where the spinal cord is pinned, then frees it by releasing the stuck portion of the cord. 14 Guideline: . Lumbar laminectomy may be appropriate and supported by evidence to improve outcomes forpatients when the patient’s medical record demonstrates a tethered spinal cord and ALL of the following: (11, 12) o Urinary dysfunction, back pain, shooting pain which extends down the legs, weakness or numbness of bilateral legs, tremor or spasm of the legs; o Progression of symptoms; o MRI or CT myelogram of the lumbosacral spine demonstrates a tethered spinal cord. Clinical Guidelines for Medical Necessity Review of Musculoskeletal Surgical Services. http://www.healthhelp.com | © 2019 HealthHelp. All rights reserved. 16945 Northchase Dr #1300, Houston, TX 77060 (281) 447‐7000 References 1. Mannion, A., Brox, J., & Fairbank, J. (2013). Comparison of spinal fusion and non- operative treatment in patients with chronic low back pain: long-term follow-up of three randomized controlled trials. The Spine Journal, 13(11), 1438-1448. 2. Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. Surgery versus conservative treatment for symptomatic lumbar spinal stenosis: a systematic review of randomized controlled trials. 2011. 3. Tyler Engel, A. S. A. "Utilization and Cost of Surgery for Lumbar Spinal Stenosis in a Commercially Insured Population." (2015). 4. Jin Jiang MD, Yuanjun Teng MD, Zhenzhen Fan MD, (2014). Does Obesity Affect the Surgical Outcome and Complication. Retrieved January 20, 2018, 2014, from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3916601/. 5. Jeffrey A. Rihn, MD, Kristen Radcliff, MD, Alan S. Hilibrand, MD, David T. Anderson, MD, (2012). Does obesity affect outcomes of treatment for lumbar stenosis. Retrieved January 20, 2018, 2012, from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3757558/ 6. Shunji Tsutsui, Ryohei Kagotani, Hiroshi Yamada et al (2012). Can decompression surgery relieve low back pain in patients. Retrieved January 20, 2018, 2012, from: https://www.ncbi.nlm.nih.gov/pmc/articles 7. Daniel K. Resnick, M.D.,1 William C. Watters III , M.D.,2 Alok Sharan, M.D.et al (2014). Guideline update for the performance of decompression procedures. Retrieved January 20, 2018, 2014, from: https://www.ncbi.nlm.nih.gov/pubmed/24980590/ 8. A. H. McGregor, A. K. Burton, P. Sell (2007). The development of an evidence-based patient booklet. Retrieved January 20, 2018, 2007, from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2200695/ 9. S. Samuel Bederman, MD, Michael H. Ford, MD, Albert J.M. Yee, MD, Joel A. Finkelstein, MD† (2006). The who, what and when of surgery lumbar spine. Retrieved January 20, 2018, 2006, from: https://www.ncbi.nlm.nih.gov/pmc/articles 10. Amundsen T, Weber H, NordalHJ, et al. Lumbar spinal stenosis: conservative or surgical management? A Prospective 10 year study. Spine 2000; 25:1424-35. 11. Shokei Yamada, MD, PhD, FACS, Professor and Former Chairman, Department of Neurosurgery, Loma Linda University Tethered Cord Syndrome; https://rarediseases.org/rare-diseases/tethered-cord-syndrome/ 12. Gupta