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Minimally invasive & 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 not required for:

  • microdisectomy, also known as percutaneous manual nucleotomy

Prior authorization is not applicable for the following procedures because these services are considered investigational/experimental. The provider and facility will be liable for payment unless:

  • The provider notifies the member that a specific service has been determined by HealthPartners to be investigational/experimental; and
  • The member signs a waiver agreeing to pay for the specific non-covered service being rendered; and
  • 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.

This list of procedures includes:

  1. Laser spine procedures, including but not limited to:
    1. laser discectomy, also known as laser-assisted discectomy, percutaneous laser discectomy, laparoscopic laser discectomy, laser disc decompression or laser-assisted disc decompression (62287)
    2. Endoscopic laser foraminoplasty
    3. Endoscopic laser foraminotomy
    4. Endoscopic laser laminotomy
    5. Laser laminectomy
  2. Automated percutaneous lumbar discectomy (APLD) (62287)
  3. Intradiscal electrothermal therapy (IDET)
  4. Nucleoplasty
  5. Transdiscal biacuplasty
  6. Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT)
  7. Intradiscal steroid injection
  8. X-close
  9. APLD (Automated percutaneous lumbar discectomy) (62287)
  10. Epidurolysis / percutaneous epidural adhesiolysis (62264, 64640)

Prior authorization is required for:

  1. Laser facet ablation / denervation /rhizotomy (64633, 64634, 64635, 64636)
  2. Intradiscal steroid injection
  3. Epidurolysis/percutaneous adhesiolysis (when coded with 64640)
  4. Minimally invasive lumbar decompression – “MILD” procedure (0274T, 0275T) - Please check Medicare for specific Medicare coverage for this procedure

Many minimally invasive back procedures are considered investigational/experimental and therefore not covered. Coverage and non coverage is listed below.

Procedures that are covered

  • Microdiscectomy, also known as percutaneous manual nucleotomy

Procedures that are not covered

The following procedures are considered investigative and not covered because the scientific evidence, to date, does not permit a conclusion to be reached regarding their efficacy.

  1. Laser spine procedures, including but not limited to:
    1. Laser discectomy, also known as laser-assisted discectomy, laser disc decompression or laser-assisted disc decompression (62287)
    2. Percutaneous laser discectomy (62287)
    3. Laparoscopic laser discectomy
    4. Endoscopic laser foraminoplasty
    5. Endoscopic laser foraminotomy
    6. Endoscopic laser laminotomy
    7. Laser laminectomy
    8. Laser facet ablation / denervation /rhizotomy (64633, 64634, 64635, 64636) 
    9. Clinical studies have not shown a clinically significant benefit of use of laser over any other method of tissue resection in spinal surgery. No additional benefit will be provided for the use of a laser in spinal surgery.
  2. APLD (Automated percutaneous lumbar discectomy) (62287)
  3. Intradiscal electrothermal therapy (IDET)
  4. Nucleoplasty (e.g., SpineWand™ coblation therapy)
  5. Transdiscal biacuplasty, aka cooled radiofrequency ablation (RFA) (22526, 22527)
  6. Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) (22526, 22527)
  7. Intradiscal steroid injection (62290, 62291, 62292, 0213T- 0218T)
  8. X-close
  9. Minimally invasive lumbar decompression – “MILD” procedure (0274T, 0275T) - Please check Medicare for specific Medicare coverage for this procedure
  10. Epidurolysis / percutaneous epidural Adhesiolysis (62263, 62264, 64640)

Lumbar disc herniation is the most common cause of sciatic pain (nerve pain radiating down the leg). Lumbar disc herniation or radiculopathy is caused when the casing around the disc bursts and some of the gel like disc material seeps out, sometimes causing pain. In some instances it presses on the sciatic nerve, causing the nerve pain radiating down the leg.

Discectomy is the incision and removal of part or the whole spinal disc. Microdiscectomy is a discectomy done with a very small incision, usually about 1 inch long using manual instruments and technique.

Percutaneous refers to the insertion of a cannula, tube or endoscope through the skin. An endoscope is a highly flexible viewing instrument with capabilities of diagnostic (biopsy) or even therapeutic functions through special channels. It looks like a large flexible needle and makes a very small incision. Many percutaneous discectomy procedures are performed by inserting the different devices through an endoscope.

Percutaneous intradiscal procedures are minimally invasive techniques providing percutaneous access to pain-generating discs. These procedures have been developed to treat discogenic LBP, including radiculopathy and sciatica by way of partial removal of the nucleus pulposus (gel like disc material) to reduce intradiscal pressure. Partial removal of the nucleus pulposus has been shown to decompress herniated discs, relieving pressure on nerve roots and, in some cases, offering relief from discogenic pain. Percutaneous intradiscal procedures may surgically extract disc material, destroy disc material or alter the disc through the application of heat.

Foraminectomy and foraminotomy are performed to expand the openings (foramen) for the nerve roots to exit the spinal cord by removing some bone and other tissue. A foraminectomy or foraminotomy is often performed on an individual who has arthritis, a lateral disc herniation, or spinal stenosis. 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.

Minimally invasive lumbar decompression (MILD) - An emerging minimally invasive surgery for lumbar spinal stenosis is known as MILD (minimally invasive lumbar decompression), a percutaneous decompression technique that increases the dimensions of the spinal canal, thereby achieving nerve decompression. The MILD procedure is an image-guided surgery—the surgical site is not directly visualized but rather surgery is guided by fluoroscopy.

Surgical Extraction Techniques

  • Percutaneous lumbar discectomy (PLD) is a term for two minimally invasive surgical techniques/intradiscal procedures for treating contained herniated discs.
  • Percutaneous manual nucleotomy refers to the technique involving the use of specialized forceps and curettes to remove the disc through a cannula.
  • APLD (Automated percutaneous lumbar discectomy) involves a probe inserted through a cannula and used both as a cutting instrument and for aspiration of disc material.

Percutaneous intradiscal decompression procedures:

  • 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 FDA approved laser discectomy devices, including LASE® (laser assisted spinal endoscopy), LADD (laser assisted disc decompression), and others.
  • Nucleoplasty, sometimes referred to as coblation therapy (e.g. SpineWand™), applies radiofrequency energy to destroy disc tissue.

Intradiscal thermal procedures are proposed to treat back pain arising from spinal disc abnormalities. The goal is to relieve pain arising from the disk and repair structural abnormalities. Heat is generated by the direct or indirect radiofrequency energy.

  • IDET (intradiscal electrothermal therapy involves a heat probe being inserted into the spine (usually via an endoscope) at the point causing pain. The tissue is heated by the probe, which causes it to shrink and scar
  • Cooled radiofrequency ablation (RFA)/Transdiscal biacuplasty is similar to IDET but is performed via a bipolar method, producing a field between two introducer needles.
  • Percutaneous intardiscal radiofrequency thermocoagulation (PIRFT) applies radiofrequency energy directly to the center of the disk.

Discography - an invasive diagnostic tool and is typically performed in conjunction with CT or MRI to localize disc herniation or fissure in the annulus fibrosis. A volume of contrast media is injected into the disc space to determine the integrity of the intervertebral disc. In the normal disc, the annulus fibrosis solidly encloses the nucleus pulposus and is only capable of accepting 1 to 1.5 ml of contrast media. If 2 ml or more of contrast media can be injected, there is likely a degenerative change in the disc. In addition to determining the available volume of the disc, discography is used to reproduce the symptoms associated with a possible herniated disc. The patient's response to pain can help confirm the source of the symptoms. When saline or dye is injected, it pressurizes the disc, and the patient is able to confirm that this pain is the same as the pain he or she has been having.

Intradiscal steroid injection is sometimes performed at the same time as a discography is performed.

If available, codes 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

63030 - Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial
facetectomy, 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

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

22899 - Unlisted procedure, spine

64999 - Unlisted procedure, nervous system

Intradiscal steroid injection

0213T–0218T - Injection(s), diagnostic or therapeutic agent, paravetebral facet (zygapophyseal)
joint (or nerves innervating that joint) with ultrasound guidance, various levels, etc.

CPT codes that require prior authorization:

Laser facet ablation / denervation /rhizotomy - These codes also refer to the policy titled: Radiofrequency ablative denervation (RFA) procedures for chronic facet-mediated neck & back pain.

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)

Intradiscal Steroid Injection

62290 - Injection procedure for discography, each level; lumbar
62291 - Injection procedure for discography, each level; cervical or thoracic
62292 - Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or
multiple levels, lumbar

Epidurolysis / percutaneous adhesiolysis

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
64640 - Destruction by neurolytic agent; other peripheral nerve or branch

Percutaneous laminotomy/laminectomy, “MILD” procedure – minimally invasive lumbar decompression

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 

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Bibliography

Bibliography available on request.

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.