Skip to main content
HealthPartners

Coverage criteria policies

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 conditions:

  1. Laser facet ablation / denervation /rhizotomy (64633, 64634, 64635, 64636)
  2. Epidurolysis / percutaneous adhesiolysis (when coded with 64640)
  3. Minimally invasive lumbar decompression – “MILD” procedure. (0274T, 0275T)

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 are considered investigational/experimental and therefore not covered.

Procedures that are covered

Microdiscectomy, also known as percutaneous manual nucleotomy

Procedures that are not covered

The following procedures are considered investigational and not covered because the reliable evidence does not permit conclusions to concerning safety, effectiveness, or effect on health outcomes.

  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 (LADD) (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)

      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.

  1. Percutaneous and endoscopic laminectomy and disc decompression procedures of the cervical, thoracic, or lumbar spine including but not limited to:
    1. Percutaneous endoscopic discectomy with or without laser (PELD) (also known as arthroscopic microdiscectomy or Yeung Endoscopic Spinal Surgery System (Y.E. S.S.))
    2. APLD (Automated percutaneous lumbar discectomy) (62287)
    3. Endoscopic procedures using the DiscFX™ System
    4. Minimally invasive lumbar decompression – “MILD” procedure. (0274T, 0275T)
  2. Thermal intradiscal procedures (TIPs) including but not limited to:
    1. Intradiscal electrothermal therapy ( IDET) / Intradiscal electrothermal annuloplasty (IEA)/ Intradiscal thermal annuloplasty (IDTA) (22526, 22527)
    2. Nucleoplasty/decompression nucleoplasty/percutaneous (or plasma) disc decompression (PDD) (e.g., SpineWand™ coblation therapy)
    3. Transdiscal biacuplasty/ Intradiscal biacuplasty (IDB)/cooled radiofrequency ablation (RFA) (22526, 22527)
    4. Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) (22526, 22527)
  3. Intradiscal steroid injection (0213T- 0218T)
  4. Devices for annulus repair (i.e. X-close)
  5. Epidurolysis / percutaneous epidural adhesiolysis (62263, 62264, 64640)
  6. Endoscopic radiofrequency denervation/rhizotomy

Definitions

Discectomy is the incision and removal of part or the whole spinal disc.

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.

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

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

  • Cooled radiofrequency ablation (RFA) / Transdiscal biacuplasty is similar to IDET but is performed via a bipolar method, producing a field between two introducer needles.
  • Intradiscal biacuplasty is a minimally invasive transdiscal radiofrequency technique for treatment of back pain. Intradiscal biacuplasty uses two internally water-cooled radiofrequency probes to lesion nociceptors in the intervertebral disc.
  • IDET (intradiscal electrothermal therapy (also known as intradiscal electrothermal annuloplasty (IDTA) or IEA) 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
  • Percutaneous intardiscal radiofrequency thermocoagulation (PIRFT) applies radiofrequency energy directly to the center of the disc.

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.

Microdiscectomy is a discectomy done with a very small incision, usually about 1 inch long using manual instruments and technique.

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.

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.

  • 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.
  • 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 symptomatic low back and leg pain caused by herniated discs. The procedure utilizes a device called the ArthroCare Perc-D SpineWand, which includes the Perc DLR, the Perc DLG and the Perc DC. The SpineWand is designed to relieve pressure on spinal nerves adjacent to the disc by removing disc material. This procedure relies on a patented technology referred to as Coblation, in which the SpineWand applies a high-frequency electric current directly to the saline medium inside the disc, generating a tightly focused field of highly energized molecules around 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 FDA approved laser discectomy devices, including LASE® (laser assisted spinal endoscopy), LADD (laser assisted disc decompression), and others.
  • 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.

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 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

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)

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

22899

Unlisted procedure, spine

64999

Unlisted procedure, nervous system

Intradiscal steroid injection

Codes

Description

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.

Codes

Description

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)

Epidurolysis / percutaneous adhesiolysis

Codes

Description

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

Codes

Description

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.

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

  1. Chou, Roger, John D. Loeser, Douglas K. Owens, Richard W. Rosenquist, Steven J. Atlas, Jamie Baisden, Eugene J. Carragee, Martin Grabois, Donald R. Murphy, Daniel K. Resnick, Steven P. Stanos, William O. Shaffer, and Eric M. Wall.(2009) "Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain." Spine 34.10: 1066-077. 
  2. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. (2009). Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine. May 1;34(10):1078-93.
  3. Chou, R. Subacute and chronic low back pain: nonsurgical interventional treatment. In: UpToDate, Atlas, SJ (Ed), UpToDate, Waltham, MA. (Accessed on June, 2017.)
  4. Chou, R. Subacute and chronic low back pain: surgical treatment. In: UpToDate, Atlas, SJ (Ed), UpToDate, Waltham, MA. (Accessed on June, 2017.)
  5. ​ECRI Institute. (2011). Laser Discectomy for the Treatment of Herniated Lumbar Discs. Plymouth Meeting, PA: ECRI Institute.
  6. ECRI Institute. (2012). Lateral and Axial Lumbar Interbody Fusion Systems for Minimally Invasive Spinal Fusion Surgery. Plymouth Meeting, PA: ECRI Institute.
  7. ECRI Institute. (2011). Minimally Invasive Lumbar Decompression for Treating Degenerative Lumbar Disease. Plymouth Meeting, PA: ECRI Institute.
  8. ECRI Institute (2016). Percutaneous Laser Disc Decompresssion for Treating Herniated Lumbar Discs. Plymouth Meeting (PA): ECRI Institute.
  9. ECRI Institute. (2012). Racz Procedure for Treating Chronic Low-back Pain. Plymouth Meeting, PA: ECRI Institute.
  10. ECRI Institute. (2012). Radiofrequency Denervation for Treating Chronic Low-Back Pain. Plymouth Meeting, PA: ECRI Institute
  11. ​ECRI Institute. Surgical Devices for Repairing Annulus Fibrosus after Discectomy. Plymouth Meeting (PA): ECRI Institute; 2015 Sep 15. (Custom Rapid Review).
  12. 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.
  13. Gibson JNA, Grant IC, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD001350.
  14. Hayes, Inc. Hayes Health Technology Brief. Endoscopic Epidural Adhesiolysis for Chronic Back Pain. Lansdale, PA: Hayes, Inc.; December, 2012.
  15. Hayes, Inc. Hayes Health Technology Brief. Endoscopic Laser-Assisted Discectomy for Cervical Disc Herniation. Lansdale, PA: Hayes, Inc.; February, 2009. Reviewed March, 2011; Archived February, 2012.
  16. Hayes, Inc. Hayes Health Technology Brief. Athroscopic Microdiscectomy for Lumbar Disc Herniation. Lansdale, PA: Hayes, Inc.; December, 2011, Reviewed June 2014. Archived, January, 2015.
  17. Hayes, Inc. Hayes Health Technology Brief. Cooled Radiofrequency Denervation of the Sacroiliac Joint for Treatment of Chronic Low Back Pain. Lansdale, PA: Hayes, Inc.; August 2011, reviewed Aug 2012; archived 2012.
  18. Hayes, Inc. Hayes Health Technology Brief. DISC Nucleoplasty® “ArthroCare Perc™-D® SpineWand™) for Percutaneous Disc Decompression. Lansdale, PA: Hayes, Inc.; December 2007, Archived January 2011.
  19. Hayes, Inc. Hayes Health Technology Brief. Minimally Invasive Lumbar Decompression (mild; Vertos Medical Inc.) for Lumbar Spinal Stenosis. Lansdale, PA: Hayes, Inc.; May, 2012. Reviewed August, 2016.
  20. Hayes, Inc. Hayes Health Technology Brief. Percutaneous Endoscopic Lumbar Discectomy for Primary Lumbar Disc Herniation. Lansdale, PA: Hayes, Inc.; March, 2017.
  21. Hayes, Inc. Hayes Health Technology Brief. Percutaneous Endoscopic Lumbar Discectomy for Recurrent Lumbar Disc Herniation. Lansdale, PA: Hayes, Inc.; March, 2017.
  22. Hayes, Inc. Hayes Health Technology Brief. Percutaneous Epidural Adhesiolysis for Chronic Back Pain. Lansdale, PA: Hayes, Inc.; October, 2012.
  23. Hayes, Inc. Hayes Medical Technology Directory Report. Automated Percutaneous Lumbar Discectomy. Lansdale, PA: Hayes, Inc.; December, 2013, Reviewed November 2017.
  24. Hayes, Inc. Hayes Medical Technology Directory Report. Intradiscal Electrothermal Therapy (IDET). Lansdale, PA: Hayes, Inc.; February 2010; Reviewed February 2014; archived March 2015.
  25. Hayes, Inc. Hayes Medical Technology Directory Report. Laser Discectomy. Lansdale, PA: Hayes, Inc.; June 2002; Reviewed April 2007; archived 2008.
  26. Hayes, Inc. Hayes Medical Technology Directory Report.Radiofrequency Ablation for Chronic Low Back Pain. Lansdale, PA: Hayes, Inc.; May 2007, Reviewed 2011.
  27. Hayes, Inc. Hayes Medical Technology Directory Report.
  28. Ablation for Sacroiliac Joint Denervation for Chronic Low Back Pain Lansdale, PA: Hayes, Inc.; June 2017, Reviewed February 2018.
  29. Hayes, Inc. Hayes Medical Technology Directory Report. Percutaneous Disc Decompression for Cervical Disc Herniation. Lansdale, PA: Hayes, Inc.; May, 2014. Reviewed April, 2016.
  30. Helm, S., Hayek, S. M., Benyamin, R. M., & Manchikanti, L. (2009). Systematic review of the effectiveness of thermal annular procedures in treating discogenic low back pain. Pain physician12(1), 207-232.
  31. Kapural, L., Hayek, S., Malak, O., Arrigain, S., & Mekhail, N. (2005). Intradiscal thermal annuloplasty versus intradiscal radiofrequency ablation for the treatment of discogenic pain: a prospective matched control trial. Pain Medicine, 6(6), 425-431.
  32. Kapural, L., & Mekhail, N. (2007). Novel intradiscal biacuplasty (IDB) for the treatment of lumbar discogenic pain. Pain Practice, 7(2), 130-134.
  33. Kapural, L., Ng, A., Dalton, J., Mascha, E., Kapural, M., Garza, M. D. L., & Mekhail, N. (2008). Intervertebral disc biacuplasty for the treatment of lumbar discogenic pain: Results of a six-month follow-up. Pain Medicine, 9(1), 60-67.
  34. Kapural, L., Sakic, K., & Boutwell, K. (2010). Intradiscal biacuplasty (IDB) for the treatment of thoracic discogenic pain. The Clinical journal of pain, 26(4), 354-357.
  35. Kumar, N., Kumar, A., Siddharth M, S., Sambhav P, S., & Tan, J. (2014). Annulo-nucleoplasty using Disc-FX in the management of lumbar disc pathology: Early results. International Journal of Spine Surgery8, 18. http://doi.org/10.14444/1018.
  36. Lu, Y., Guzman, J. Z., Purmessur, D., Iatridis, J. C., Hecht, A. C., Qureshi, S. A., & Cho, S. K. (2014). Nonoperative Management of Discogenic Back Pain. Spine, 39(16), 1314-1324. doi:10.1097/brs.0000000000000401
  37. Manchikanti L, Abdi S, Atluri S, Benyamin RM, et al (2013). An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. Apr;16(2 Suppl):S49-283. PubMed PMID: 23615883
  38. Manchikanti L, Falco FJ, Benyamin RM, et al. (2013). An update of the systematic assessment of mechanical lumbar disc decompression with nucleoplasty. Pain Physician 16(2 Suppl):SE25-SE54.
  39. Manchikanti L, Singh V, Kloth D, Slipman CW, Jasper JF, Trescot AM, et al. (2001). Interventional techniques in the management of chronic pain: part 2.0. ASIPP Practice Guidelines. Pain Physician. 4(1):24-98.
  40. Yeung, A., & Gore, S. (2014). Endoscopically guided foraminal and dorsal rhizotomy for chronic axial back pain based on cadaver and endoscopically visualized anatomic study. International journal of spine surgery8.