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DESCRIPTIONFor laser disectomy under fluoroscopic guidance, a needle or catheter is inserted into the disc nucleus and a laser beam directed through it to vaporize tissue.
For disc nucleoplasty, bipolar radiofrequency energy is directed into the disc to ablate tissue.
A variety of minimally invasive techniques have been investigated over the years as a treatment of low back pain related to disc disease. Techniques can be broadly divided into techniques that are designed to remove or ablate disc material and thus decompress the disc or those that are designed to alter the biomechanics of the disc annulus. The former category includes chymopapain injection, automated percutaneous lumbar discectomy, laser discectomy, and most recently disc decompression using radiofrequency energy, referred to as a DISC nucleoplastyTM. Techniques that alter the biomechanics of the disc include intradiscal electrothermal annuloplasty (i.e., the IDET procedure) or percutaneous intradiscal radiofrequency thermocoagulation (PIRT). It should be noted that 3 of these procedures use radiofrequency energy - disc nucleoplasty, IDET and PIRT – but apply the energy in distinctly different ways such that the procedures are unique and are considered separately.* Note also that the IDET and PIRT procedure, chymopapain injection, and automated percutaneous lumber discectomy are considered in a separate policies. Laser discectomy and DISC nucleoplastyTM are the subjects of this policy. (For further discussion on the distinction between IDET, PIRT and DISC nucleoplastyTM see note below*.)
A variety of different lasers have been investigated for laser discectomy, including YAG, KTP, holmium, argon, and carbon dioxide lasers. Regardless of the type of laser, the procedure involves placement of the laser within the nucleus under fluoroscopic guidance and then activated. Due to differences in absorption, the energy requirements and the rate of application differ among the lasers. In addition, it is unknown how much disc material must be removed to achieve decompression. Therefore, protocols vary according to the length of treatment, but typically the laser is activated for brief periods only.
The Disc nucleoplastyTM procedure uses bipolar radiofrequency energy in a process referred to as coblation technology. The technique consists of small, multiple electrodes that emit a fraction of the energy required by traditional radiofrequency energy systems. The result is that a portion of nucleus tissue is ablated not with heat, but with a low-temperature plasma field of ionized particles. These particles have sufficient energy to break organic molecular bonds within tissue, creating small channels in the disc. The proposed advantage of this coblation technology is that the procedure provides for a controlled and highly localized ablation, resulting in minimal therapy damage to surrounding tissue.
Patients considered candidates for DISC nucleoplastyTM or laser discectomy include patients with bulging discs and sciatica. In contrast, the presence of a herniated disc is typically considered a contraindication for the IDET or PIRT procedure.
*Note: PIRT describes the direct application of radiofrequency energy to the disc material to gently heat the disc material for 90 seconds at a temperature of 70 degrees centigrade. This procedure is not designed to ablate disc material but to alter the biomechanics of the disc or by destroying nociceptive pain fibers. The IDET procedure involves the use of radiofrequency energy, which is translated into electrothermal heat using an electroresistive coil. The coil is placed along the annulus, which is then heated for up to 20 minutes. Similar to the PIRT procedure, IDET is not designed to coagulate, burn, or ablate tissue. Again, the mechanism of action is not well understood, but is thought to be related to either shrinkage of the collagen fibers within the annulus or destruction of the adjacent nociceptive pain fibers. Both of these procedures contrast with DISC nucleoplastyTM, which while also using radiofrequency energy, in contrast to the above procedure is specifically designed to ablate disc material and thus decompress the disc.
See separate policy for Percutaneous Lumbar Discectomy .
A number of laser devices have received FDA 510(k) clearance for incision, excision, resection, ablation, vaporization, and coagulation of tissue. Intended uses described in FDA summaries include a wide variety of procedures including percutaneous discectomy. Trimedyne, Inc. received 510(k) clearance in 2002 for the Trimedyne Holmium Laser System Ho1mium:Yttrium Aluminum Garnet (Ho1mium:YAG), Lisa Laser Products for Revolix Duo Laser System in 2007, and Quanta System LITHO Laser System in 2009. All were cleared, based on equivalence with predicate devices, for percutaneous laser disc decompression/discectomy including foraminoplasty, percutaneous cervical disc decompression/discectomy, and percutaneous thoracic disc decompression/discectomy. The summary for the Trimedyne system states that indications for cervical and thoracic decompression/discectomy include uncomplicated ruptured or herniated discs, sensory changes, imaging consistent with findings, and symptoms unresponsive to 12 weeks of conservative treatment. Indications for treatment of cervical discs also include positive nerve conduction studies.
Arthrocare’s Perc-D SpineWand received 510(k) clearance in 2001 based on equivalence to predicate devices. It is used in conjunction with the Arthrocare Coblation System 2000 for ablation, coagulation, and decompression of disc material to treat symptomatic patients with contained herniated discs.
POLICYLaser Discectomy and DISC nucleoplastyTM are considered investigational as techniques of disc decompression and treatment of associated pain.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY11/2002:Approved by Medical Policy Advisory Committee (MPAC)
8/26/2003: ICD-9 diagnosis code ranges 722.51-722.52, 722.90-722.93 listed separately
3/10/2004: Code Reference section reviewed, no changes
3/25/2004: Reviewed by MPAC, title "Laser Discectomy" renamed "Decompression of Intervertebral Discs Using Laser (Laser Discectomy) or Radiofrequency Energy (DISC NucleoplastyTM)", Laser discectomy remains investigational, DISC nucleoplastyTM considered investigational, Description section revised to be consistent with BCBSA policy # 7.01.93
5/3/2004: Code Reference section updated, CPT code 62287 "For fluoroscopic guidance, use 76003" added, CPT code 76003 added, ICD-9 diagnosis code 722.0, 722.10, 722.2, 722.4, 722.51, 722.52, 722.6, 722.90, 722.91, 722.92, 722.93 deleted
8/1/2005: Code Reference section updated, HCPCS S2348 with effective date 1/1/2005 added
12/27/2006: Code Reference section updated per the 2007 CPT revisions
9/18/2007: Policy reviewed, no changes
12/31/2008: CPT 62267 added as non-covered; CPT 62287 description revised
4/6/2009: Policy reviewed, no changes
07/15/2010: Policy title updated to change the term "Radiofrequency Energy" to "Radiofrequency Coblation." Policy description updated to include information regarding the availability and FDA status of laser devices. Policy statement unchanged. FEP verbiage added to the Policy Exceptions section.
08/03/2011: Policy reviewed. Policy statement unchanged. Deleted outdated references from the Sources section.
09/25/2012: Policy reviewed; no changes.
11/06/2013: Policy reviewed; no changes.
SOURCE(S)Blue Cross Blue Shield Association policy # 7.01.93
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.