Automated Percutaneous and Percutaneous Endoscopic Discectomy

POLICY NUMBER

A.7.01.18

DESCRIPTION

Surgical management of herniated intervertebral discs most commonly involves discectomy and microdiscectomy, performed manually through an open incision. Automated percutaneous discectomy involves placement of a probe within the intervertebral discunder image guidance with aspiration of disc material using a suction cutting device. Endoscopic discectomy involves the percutaneous placement of a working channel under image guidance, followed by visualization of the working space and instrumentation through an endoscope, and aspiration of disc material.

Back pain or radiculopathy related to herniated discs is an extremely common condition and a frequent cause of chronic disability. Although many cases of acute low back pain and radiculopathy will resolve with conservative care, surgical decompression is often considered when the pain is unimproved after several months and is clearly neuropathic in origin, resulting from irritation of the nerve roots. Open surgical treatment typically consists of discectomy, in which the extruding disc material is excised. When performed with an operating microscope, the procedure is known as microdiscectomy.

Minimally invasive options have also been researched, in which some portion of the disc is removed or ablated, although these techniques are not precisely targeted at the offending extruding disc material. Ablative techniques include laser discectomy and radiofrequency decompression. This is discussed in the  Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) medical policy. Intradiscal electrothermal annuloplasty is another minimally invasive approach to low back pain. In this technique, radiofrequency energy is used to treat the surrounding disc annulus (see the Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty  medical policy).

This policy addresses automated percutaneous and endoscopic discectomy, in which the disc decompression is accomplished by the physical removal of disc material rather than its ablation. Traditionally, discectomy was performed manually through an open incision, using cutting forceps to remove nuclear material from within the disc annulus. This technique was modified by automated devices that involve placement of a probe within the intervertebral disc and aspiration of disc material using a suction cutting device. Endoscopic techniques may be intradiscal or may involve extraction of noncontained and sequestered disc fragments from inside the spinal canal using an interlaminar or transforaminal approach. Following insertion of the endoscope, the decompression is performed under visual control.

The DeKompressor® Percutaneous Discectomy Probe (Stryker), Herniatome Percutaneous Discectomy Device (Gallini Medical Devices), and the Nucleotome® (Clarus Medical) are examples of percutaneous discectomy devices that have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. The FDA indication for these products is for “aspiration of disc material during percutaneous discectomies in the lumbar, thoracic and cervical regions of the spine."

A variety of endoscopes and associated surgical instruments have been cleared for marketing by the FDA through the 510(k) process.

POLICY

Automated percutaneous discectomy is considered investigational as a technique of intervertebral disc decompression in individuals with back pain and/or radiculopathy related to disc herniation in the lumbar, thoracic, or cervical spine.

Percutaneous endoscopic discectomy is considered investigational as a technique of intervertebral disc decompression in individuals with back pain and/or radiculopathy related to disc herniation in the lumbar, thoracic, or cervical spine.

POLICY EXCEPTIONS

Federal 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.

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

11/2000: Approved by Medical Policy Advisory Committee (MPAC)

7/3/2001: ICD-9 code range 722.0-722.9 deleted

2/11/2002: Investigational definition added

5/2/2002: Type of Service and Place of Service deleted

6/11/2002: HCPCS code S2370 added

11/2002: Hyperlink added

9/29/2003: HCPCS S2370 deleted

3/25/2004: Reviewed by MPAC, remains investigational, FEP exception added

5/19/2004: Code Reference section updated, CPT code 62287 description revised, ICD-9 diagnosis code 722.52, 722.73 description revised.

1/22/2007: Policy reviewed, discussion rewritten for clarity, no changes in policy statement.

12/19/2008: Policy reviewed, no changes.

12/31/2008: CPT code 62267 added as non-covered; CPT code 62287 description revised.

04/23/2010: Policy title changed from “Percutaneous Lumbar Discectomy” to “Automated Percutaneous Discectomy.” Policy description updated regarding devices; added links to related policies. Policy statement unchanged. FEP verbiage added to the Policy Exceptions section. Deleted outdated references in the Sources section.

04/20/2011: Policy reviewed; no changes.

02/24/2012: Policy reviewed; no changes.

04/11/2012: Add the following policy statement: Endoscopic discectomy is considered investigational as a technique of intervertebral disc decompression in patients with back pain related to disc herniation in the lumbar, thoracic, or cervical spine. Added "Endoscopic" to the policy title.

05/06/2013: Policy statement revised to state "back pain and/or radiculopathy" for clarity purposes. Added CPT codes 0274T and 0275T to the Code Reference section. Removed ICD-9 diagnosis codes 722.52 and 722.73 from the Code Reference section.

06/13/2014: Policy reviewed; description updated. Added "Automated" to the first policy statement on percutaneous discectomy for clarity purposes; intent unchanged.

08/25/2015: Code Reference section updated for ICD-10.

09/14/2015: Policy description updated. Policy statements unchanged. Investigative definition updated in Policy Guidelines section.

05/31/2016: Policy number A.7.01.18 added.

08/15/2016: Policy description updated. Policy statements unchanged.

12/30/2016: Code Reference section updated to revise code descriptions for CPT codes 62287, 0274T, and 0275T.

09/15/2017: Policy title changed from "Automated Percutaneous and Endoscopic Discectomy" to "Automated Percutaneous and Percutaneous Endoscopic Discectomy." Policy description updated regarding devices. Investigational statement updated to change "endoscopic discectomy" to "percutaneous endoscopic discectomy." Code Reference section updated to add CPT code 62380.

01/23/2019: Policy description updated with minor changes. Policy statements unchanged.

07/16/2019: Policy reviewed; no changes.

07/15/2020: Policy reviewed; no changes.

08/26/2021: Policy description updated. Policy statements unchanged.

07/15/2022: Policy reviewed. Policy statements updated to change "patients" to "individuals."

08/02/2023: Policy reviewed; no changes.

07/24/2024: Policy reviewed; no changes.

08/25/2025: Policy reviewed; no changes.

01/01/2026: Code Reference section updated to add new CPT codes 62330 and 62331.

01/15/2026: Code Reference section updated to revise the descriptions of CPT codes 62287 and 0274T. Effective 01/01/2026.

SOURCE(S)

Blue Cross Blue Shield Association policy #7.01.18

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

Investigational Codes

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