DescriptionSpinal decompression surgery is a general term encompassing various procedures intended to relieve symptoms caused by pressure or compression on the spinal cord and/or spinal nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, corpectomy, facetectomy, foraminectomy, foraminotomy, laminectomy, laminotomy, spinal fusion or a combination of these procedures. For information regarding spinal fusion, please refer to Spinal Fusion Surgery Medical Coverage Policy.Discectomy (diskectomy) is the most common surgical treatment for ruptured or herniated discs, particularly of the lumbar spine, though it may also be used on the cervical or thoracic spine. During a discectomy, the surgeon removes the section of the disc that is protruding from the disc wall and any other disc fragments that may be pressing on a nerve root or the spinal cord. A discectomy may be open (via aPage: 1 of 36Spinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 2 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.relatively large surgical incision through the skin, muscle and other structures) or it may be performed microscopically (known as a microdiscectomy). Both procedures allow for direct visualization of the vertebra, disc and other surrounding structures. The microdiscectomy utilizes a special microscope or magnifying instrument to view the disc and nerves, which makes it possible to remove the disc material through a smaller incision. This smaller incision reduces the risk of damage to the surrounding tissues, which decreases the potential complications.Minimally invasive approaches for discectomy may also be offered as a treatment option by some surgeons. They may utilize either an endoscopic or laparoscopic approach for the procedure, which still allows direct visualization of the surgical field and anatomy. These procedures may also be referred to as arthroscopic microdiscectomy. Examples of these procedures or the devices that may be used include, but may not be limited to, the CESSYS (dorsal and ventral), iLESSY, iLESSY Delta, iLESSYS Pro, METRx system (X-tube), microendoscopic discectomy (MED), posterolateral endoscopic lumbar discectomy (PELD), TESSYS, TESSYS Thx, tubular microdiskectomy or Yeung Endoscopic Spinal System (YESS).A corpectomy is a procedure to remove the body of a vertebra, as well as the disc. This is most commonly performed in the cervical spine and usually in conjunction with a fusion.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. 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. A foraminectomy or foraminotomy is often performed on an individual who has arthritis, a lateral disc herniation or spinal stenosis.Microsurgical anterior foraminotomy is a procedure used for the treatment of cervical radiculopathy caused by a narrowing of the foramen. Microsurgical instruments are used through a small incision, which is proposed to decrease damage to surrounding tissue and/or the lamina or facets.Laminectomy and laminotomy involves removal of a small part of the bony arches of the spinal canal, called the lamina, which increases the size of the spinal canal. A laminectomy or laminotomy is most commonly performed for a diagnosis of spinalSpinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 3 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.stenosis. During a laminectomy, the entire lamina is removed while only a portion of the lamina is removed in a laminotomy. These procedures are also often done with either a discectomy or a foraminectomy/foraminotomy.Minimally invasive approaches for laminectomy, laminotomy, foraminectomy or foraminotomy have also been proposed as a newer treatment option by some surgeons. They may utilize either an endoscopic or laparoscopic approach for the procedure, which allows direct visualization of the surgical field.During laminoplasty the laminae are split and then held apart by bone struts, sutures or other techniques to enlarge the spinal canal diameter. This procedure is usually performed on the cervical spine and may be used in an effort to lessen the chance of deformity that can develop when a facetectomy or laminectomy is performed alone.A number of alternative approaches to discectomy have also been proposed; they include, but may not be limited to, the following:Automated percutaneous lumbar discectomy (APLD), or automated percutaneous mechanical lumbar discectomy, performed under local anesthesia and fluoroscopic guidance, involves insertion of a cannula into the affected disc; an automated cutting and aspiration device is then placed through the cannula and the disc material is removed. APLD does not allow direct visualization of the disc or surrounding tissues. An example of a device used for this type of procedure includes, but may not be limited to, the Stryker Dekompressor Lumbar Discectomy System. (Refer to Coverage Limitations section)The Disc-FX System is proposed as a minimally invasive alternative to discectomy, combining endoscopic disc decompression, nucleus ablation (utilizing radiofrequency energy) and annulus modulation (sealing tears in the annulus). The procedure is performed under local anesthesia on discs in the cervical, thoracic or lumbar spine. (Refer to Coverage Limitations section)Laser discectomy may also be referred to as laser-assisted discectomy, laser disc decompression or laser-assisted disc decompression (LADD). Though this procedure is called a discectomy, it does not actually remove the disc, but utilizes a laser to vaporize a small portion of the nucleus pulposus in order to purportedlySpinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 4 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.decompress a herniated disc. Laser discectomy may be performed either laparoscopically or percutaneously. (Refer to Coverage Limitations section)Laparoscopic laser discectomy is done through a laparoscope, which allows visualization of the disc, disc space and other structures. The annulus of the disc is opened and is then excised with a laser device which is inserted through the laparoscope. (Refer to Coverage Limitations section)Percutaneous laser discectomy (also referred to as percutaneous laser disc decompression [PLDD]) is performed under a local anesthetic. Under fluoroscopic guidance, a needle is inserted through the skin into the disc. A flexible quartz fiber is then threaded through the needle and into the disc, which delivers the laser energy. (Refer to Coverage Limitations section)Percutaneous procedures have also been proposed as an alternative surgical approach for laminectomy, laminotomy, foraminectomy or foraminotomy. The percutaneous procedures are generally performed in an outpatient setting with the individual awake but sedated. Percutaneous image-guided spinal procedures do not allow direct visualization of the surgical field. An example of percutaneous image- guided decompression procedures for lumbar spinal stenosis is the MILD procedure which utilizes trocars to access the area of stenosis (resection of the ligamentum flavum). (Refer to Coverage Limitations section)An annular (annulus) repair/closure may be performed following a spinal decompression (discectomy) surgery. It has been proposed that annular closure may reduce the risk of disc reherniation and the future need for a fusion. An example of a device used in an annular repair includes, but may not be limited to, the Barricaid Anular Closure Device. An additional technique for annular repair, the Discseel procedure, has also been developed. This technique identifies the annular defect (tear) via an annulogram; fibrin is then injected into the tear(s), which theoretically seals the damaged disc and then purportedly promotes tissue growth and healing. This may also be referred to as Discseel Regenerative Spine Procedure. (Refer to Coverage Limitations section)For information regarding other back pain treatments or procedures, please refer to the following:Spinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 5 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| Medical Coverage Policy | | Dynamic Spinal Stabilization Devices |
| Electrothermal Intradiscal Therapies |
| Injections for Chronic Pain Conditions |
| Interspinous Process Decompression Spacers |
| Neuroablative Techniques for Chronic Pain Percutaneous Vertebroplasty, Kyphoplasty (Balloon-Assisted Vertebroplasty), |
Coverage Determination|Discectomy Humana members may be eligible under the Plan for discectomy (including microdiscectomy or minimally invasive approaches for discectomy) for the following indications:• Evidence of myelopathy, confirmed by diagnostic imaging studies with BOTH of the following:o Corresponding clinical symptoms including, but may not be limited to:Bladder or bowel incontinence; OR Clumsiness of the hands; OR Frequent falls; OR Urinary urgency; ANDo Corresponding objective neurological signs including, but may not be limited to:Hoffman sign; OR Hyperreflexia; OR Increased tone or spasticity; OR• Herniated disc, confirmed by diagnostic imaging studies when accompanied by the following:Spinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 6 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.o Radicular* pain that has persisted despite 6 weeks of conservative treatment under the direction of a healthcare professional, including ALL of the following:Activity/lifestyle modification; ANDEpidural steroid injections or facet joint/medial branch nerve blocks if medically appropriate and not contraindicated (for information regarding coverage determination/limitations, please refer to Injections for Chronic Pain Conditions Medical Coverage Policy); ANDMedications (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], non- narcotic analgesics) if medically appropriate and not contraindicated; ANDPhysical therapy (PT), including a home exercise program (HEP) (for information regarding coverage determination/limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy); OR• Rapidly progressive neurological signs/symptoms of lumbar spine compression confirmed by diagnostic imaging studies; OR• Spinal fractures confirmed by diagnostic imaging studies; OR• Spinal infection confirmed by diagnostic imaging studies; OR• Spinal tumor confirmed by diagnostic imaging studies*Lumbar (low back) radicular pain typically radiates to the level of the knee or more distally and is associated with segmental nerve root impingement. Cervical (neck) radicular pain typically radiates down one or both arms and is associated with segmental nerve root impingement.LAMINECTOMY, LAMINOTOMY, FORAMINECTOMY, FORAMINOTOMY, FORAMINOLAMINECTOMYSpinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 7 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.Cervical Spine Humana members may be eligible under the Plan for a cervical laminectomy, laminotomy, foraminectomy, foraminotomy (including microsurgical anterior foraminotomy) or foraminolaminectomy for the following indications:• Congenital cervical spinal stenosis; OR• Cord compression as a result of rheumatoid arthritis (usually performed with a spinal fusion) (for information regarding coverage determination/limitations for spinal fusion, please refer to Spinal Fusion Surgery Medical Coverage Policy); OR• Degenerative spondylolisthesis (usually performed with a spinal fusion) (for information regarding coverage determination/limitations for spinal fusion, please refer to Spinal Fusion Surgery Medical Coverage Policy); OR• Evidence of myelopathy confirmed by diagnostic imaging studies with BOTH of the following:o Corresponding clinical symptoms including, but may not be limited to:Bladder or bowel incontinence; OR Clumsiness of the hands; OR Foot drop; OR Frequent falls; OR Urinary urgency; ANDo Corresponding objective neurologic signs including, but may not be limited to:Hoffman sign; OR Hyperreflexia; OR Increased tone or spasticity; OR• Herniated disc, foraminal stenosis or spinal stenosis at the level corresponding with clinical findings confirmed by diagnostic imaging studies when accompanied by BOTH of the following:Spinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 8 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.o Physical and neurological abnormalities suggestive of nerve root or spinal cord compression (eg, weakness, sensory loss, reflex changes); ANDo Radicular* pain that has persisted despite 6 weeks of conservative treatment under the direction of a healthcare professional, including ALL of the following:Activity/lifestyle modification; ANDEpidural steroid injections or facet joint/medial branch nerve blocks if medically appropriate and not contraindicated (for information regarding coverage determination/limitations, please refer to Injections for Chronic Pain Conditions Medical Coverage Policy); ANDMedications (eg, NSAIDs, non-narcotic analgesics) if medically appropriate and not contraindicated; ANDPT, including an HEP (for information regarding coverage determination/ limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy); OR• Ossification of the posterior longitudinal ligament (three or more levels) with cord compression confirmed by diagnostic imaging studies; OR• Rapidly progressive neurologic signs/symptoms of cervical spine compression confirmed by diagnostic imaging studies; OR• Spinal fractures confirmed by diagnostic imaging studies; OR• Spinal infection confirmed by diagnostic imaging studies; OR• Spinal injury from epidural hematoma; OR• Spinal injury from foreign bodies; OR• Spinal tumor confirmed by diagnostic imaging studiesSpinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 9 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.Lumbar Spine Humana members may be eligible under the Plan for lumbar laminectomy, laminotomy, foraminectomy, foraminotomy or foraminolaminectomy for the following indications:• Cauda equina syndrome (bowel or bladder dysfunction, bilateral lower extremity weakness/numbness/decreased sensation, saddle anesthesia) confirmed by diagnostic imaging studies; OR• Herniated disc, foraminal stenosis or spinal stenosis at the level corresponding with clinical findings confirmed by diagnostic imaging studies when accompanied by BOTH of the following:o Physical and/or neurological abnormalities suggestive of nerve root or spinal cord compression (eg, weakness, sensory loss, reflex change); ANDo Radicular* pain that has persisted despite 6 weeks of conservative treatment under the direction of a healthcare professional, including ALL of the following:Activity/lifestyle modification; ANDEpidural steroid injections or facet joint/medial branch nerve blocks if medically appropriate and not contraindicated (for information regarding coverage determination/limitations, please refer to Injections for Chronic Pain Conditions Medical Coverage Policy); ANDMedications (eg, NSAIDs, non-narcotic analgesics) if medically appropriate and not contraindicated; ANDPT, including an HEP (for information regarding coverage determination/ limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy); OR• Rapidly progressive neurologic signs/symptoms of lumbar spine compression confirmed by diagnostic imaging studies; ORSpinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 10 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.• Spinal fractures confirmed by diagnostic imaging studies; OR• Spinal infections confirmed by diagnostic imaging studies; OR• Spinal injury from epidural hematoma; OR• Spinal injury from foreign bodies; OR• Spinal tumor confirmed by diagnostic imaging studies; OR• Spondylolisthesis (usually performed with a spinal fusion) (for information regarding coverage determination/limitations for spinal fusion, please refer to Spinal Fusion Surgery Medical Coverage Policy)Thoracic Spine, Sacrum Humana members may be eligible under the Plan for thoracic or sacral laminectomy, laminotomy, foraminectomy, foraminotomy or foraminolaminectomy for the following indications:• Spinal fractures confirmed by diagnostic imaging studies; OR• Spinal infection confirmed by diagnostic imaging studies; OR• Spinal injury from epidural hematoma; OR• Spinal injury from foreign bodies; OR• Spinal tumor confirmed by diagnostic imaging studiesLaminoplasty Humana members may be eligible under the Plan for a laminoplasty for the following indications:Lumbar or thoracic spinal tumor; OR• Evidence of severe cervical spinal stenosis at multiple (3 or more) levels with compressive myelopathy, confirmed by diagnostic imaging studies; ANDSpinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 11 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.• Symptoms of multilevel compressive myelopathy including, but may not be limited to:o Bladder or bowel incontinence; OR o Clumsiness of the hands; OR o Foot drop; OR o Frequent falls; OR o Urinary urgency; AND• Objective neurological signs of multilevel compressive myelopathy including, but may not be limited to:o Hoffman sign; OR o Hyperreflexia; OR o Increased tone or spasticityCorpectomy Humana members may be eligible under the Plan for corpectomy for the following indications:• Evidence of spinal cord or nerve root compression, confirmed by diagnostic imaging studies AND ONE of the following conditions:o Degenerative disease due to one of the following:Developmental stenosis demonstrating an osseous anterior/posterior (AP) canal diameter of less than 10 mm; ORFree disc fragment that has migrated posterior to the vertebral body; ORLarge posterior osteophyte adjacent to the end plate; ORo Infection (osteomyelitis, discitis); ORo Ossification of the posterior longitudinal ligament (if treated anteriorly); ORSpinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 12 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.o Trauma (vertebral fractures) in the cervical, thoracic or lumbar regions; ORo Tumors in the cervical, thoracic or lumbar regionsCoverage LimitationsHumana members may NOT be eligible under the Plan for discectomy (including microdiscectomy or minimally invasive approaches for discectomy) for any indications other than those listed above (in the Coverage Determination section). These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.Humana members may NOT be eligible under the Plan for any other type of discectomy procedure for any indication including, but may not be limited to:• Automated percutaneous lumbar discectomy (APLD) (also known as automated percutaneous mechanical lumbar discectomy) including, but not be limited to, the Stryker Dekompressor Lumbar Discectomy Probe; OR• Endoscopic disc decompression, when in combination with ablation (radiofrequency ablation) and annulus modulation/repair including, but not limited to, the Disc-FX system; OR• Laser discectomy, regardless of the approach, including percutaneous laser discectomy, laser-assisted discectomy, laser disc decompression, laser-assisted disc decompression or percutaneous laser disc decompression; OR• Percutaneous discectomy techniques not previously listed including, but not limited to, the HydroCision/HydroDiscectomyThese are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.Spinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 13 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.Humana members may NOT be eligible under the Plan for laminectomy, laminotomy, foraminectomy, foraminotomy (including microsurgical anterior foraminotomy), foraminolaminectomy, laminoplasty or corpectomy for any indications other than those listed above (in the Coverage Determination section). These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.Humana members may NOT be eligible under the Plan for any other type of laminectomy, laminotomy, foraminectomy, foraminotomy, foraminolaminectomy, laminoplasty, corpectomy or decompression procedure for any indication including, but not limited to:• ANY PERCUTANEOUS laminectomy, laminotomy, foraminectomy, foraminotomy, foraminotomy, foraminolaminectomy, laminoplasty or corpectomy; OR• Laser laminectomy; OR• Percutaneous image-guided lumbar decompression including, but not be limited to, the MILD procedure (resection of ligamentum flavum)These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.Note: The criteria for percutaneous image-guided lumbar decompression are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.Humana members may NOT be eligible under the Plan for annular (annulus) fibrosis repair/closure via any technique including, but not limited to:Spinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 14 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.Barricaid Anular Closure Device; OR • Discseel Procedure (Discseel Regenerative Spine Procedure)This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.Humana members may NOT be eligible under the Plan for spinal decompression surgery procedures performed with systems using artificial intelligence or augmented reality guidance including, but not limited to, the Surgalign Holo Portal surgical guidance system or the Caduceus S augmented reality spine navigation system. These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.BackgroundAdditional information about back or neck pain, degenerative disc disease, spinal stenosis and other spinal conditions may be found from the following websites:National Institute of Neurological Disorders and Stroke • National Library of Medicine • North American Spine SocietyMedical AlternativesAlternatives to corpectomy include, but may not be limited to, the following:• Physical therapy (PT) (please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy)• Prescription drug therapy• Spinal fusion (please refer to Spinal Fusion Surgery Medical Coverage Policy)Spinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 15 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.• Therapeutic pain injections (eg, epidural steroid injections) (please refer to Injections for Chronic Pain Conditions Medical Coverage Policy)Alternatives to endoscopic laser laminectomy include, but may not be limited to, the following:• Laminectomy using a traditional surgical approach• Prescription drug therapy• PT (please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy)• Therapeutic pain injections (eg, epidural steroid injections) (please refer to Injections for Chronic Pain Conditions Medical Coverage Policy)Alternatives to laminoplasty include, but may not be limited to, the following:• Prescription drug therapy• PT (please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy)• Spinal fusion (please refer to Spinal Fusion Surgery Medical Coverage Policy)• Therapeutic pain injections (eg, epidural steroid injections) (please refer to Injections for Chronic Pain Conditions Medical Coverage Policy)Alternatives to laser discectomy, arthroscopic microdiscectomy or APLD include, but may not be limited to, the following:• Discectomy using a traditional surgical approach• Prescription drug therapySpinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 16 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.• PT (please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy)• Therapeutic pain injections (eg, epidural steroid injections) (please refer to Injections for Chronic Pain Conditions Medical Coverage Policy)Alternatives to microsurgical anterior foraminotomy include, but may not be limited to, the following:• Foraminotomy using a traditional surgical approachPhysician consultation is advised to make an informed decision based on an individual’s health needs.
| Codes | informational purposes only. Do not rely on the accuracy and inclusion of specifi |
Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.
| cPT® Code(s) | Description | Comments | | 22100 | Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical | |
| 22101 | Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracic | |
| 22102 | Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar | |
Spinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 17 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 22103 | process, lamina or facet) for intrinsic bony lesion, single vertebral segment; each additional segment (List separately in addition to code for primary procedure) | |
| 22899 | Unlisted procedure, spine | Not Covered if used to report any procedure outlined in Coverage Limitations section |
| 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 discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar | Not Covered |
| 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 | |
| 63001 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical | |
| 63003 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; thoracic | |
| 63005 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis | |
| 63011 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; sacral | |
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| this is the 63012 | current version before utilizing. Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) | |
| 63015 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; cervical | |
| 63016 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; thoracic | |
| 63017 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar | |
| 63020 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical | |
| 63030 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar | Not Covered if used to report any procedure outlined in Coverage Limitations section |
| 63035 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure) | |
| 63040 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical Laminotomy (hemilaminectomy), with decompression of nerve | Not Covered if used to |
63042Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbarNot Covered if used to report any procedure outlined in Coverage Limitations sectionSpinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 19 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 63043 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (List separately in addition to code for primary procedure) |
| 63044 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace (List separately in addition to code for primary procedure) |
| 63045 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical |
| 63047 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar |
| 63048 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) |
| 63050 | Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; |
| Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the |
Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices [eg, wire, suture, mini-plates], when performed)Spinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 20 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 63055 | Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic | | | 63056 | Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or latera extraforaminal approach) (eg, far lateral herniated intervertebral disc) | |
| 63057 | Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure) | |
| 63064 | Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; single segment | |
| 63066 | Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; each additional segment (List separately in addition to code for primary procedure) | |
| 63075 | Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace | |
| 63076 | Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure) | |
| 63077 | Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, single interspace | |
| 63078 | Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, each additional interspace (List separately in addition to code for primary procedure) | |
Spinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 21 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 63081 | Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment |
| 63082 | Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for primary procedure) |
| 63085 | Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment |
| 63086 | Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, each additional segment (List separately in addition to code for primary procedure) |
| 63087 | Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment |
| 63088 | Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; each additional segment (List separately in addition to code for primary procedure) |
| 63090 | Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment |
| 63091 | Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment (List separately in addition to code for primary procedure) |
Spinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 22 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 63101 | Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of . spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic, single segment |
| 63102 | Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); lumbar, single segment |
| 63103 | Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic or lumbar, each additional segment (List separately in addition to code for primary procedure) |
| 63170 | Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar |
| 63172 | Laminectomy with drainage of intramedullary cyst/syrinx; to subarachnoid space |
| 63173 | Laminectomy with drainage of intramedullary cyst/syrinx; to peritoneal or pleural space |
| 63185 | Laminectomy with rhizotomy; 1 or 2 segments |
| 63190 | Laminectomy with rhizotomy; more than 2 segments |
| 63191 | Laminectomy with section of spinal accessory nerve |
| 63197 | Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage, thoracic |
| 63200 | Laminectomy, with release of tethered spinal cord, lumbar |
| 63250 | Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; cervical |
| 63251 | Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracic |
| 63252 | Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar |
Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar Laminectomy with drainage of intramedullary cyst/syrinx; to subarachnoid space Laminectomy with drainage of intramedullary cyst/syrinx; to peritoneal or pleural space Laminectomy with rhizotomy; 1 or 2 segments Laminectomy with rhizotomy; more than 2 segments Laminectomy with section of spinal accessory nerve Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage, thoracic Laminectomy, with release of tethered spinal cord, lumbar Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; cervical Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracic Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic63266Spinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 23 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 63267 | Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar | | 63268 | Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral |
| 63270 | Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical |
| 63271 | Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; thoracic |
| 63272 | Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar |
| 63273 | Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; sacral |
| 63275 | Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical |
| 63276 | Laminectomy for biopsy/excision of intraspinal neoplasm; . extradural, thoracic |
| 63277 | Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar |
| 63278 | Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, sacral |
| 63280 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, cervical |
| 63281 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, thoracic |
| 63282 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar |
| 63283 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, sacral |
| 63285 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical |
| 63286 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracic |
| 63287 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracolumbar |
Spinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 24 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 63290 | Laminectomy for biopsy/excision of intraspinal neoplasm; . . . combined extradural-intradural lesion, any level | | 63295 | Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure (List separately in addition to code for primary procedure) |
| 63300 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, cervical |
| 63301 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by transthoracic approach |
| 63302 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by thoracolumbar approach |
| 63303 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, lumbar or sacral by transperitoneal or retroperitoneal approach |
| 63304 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, cervical |
| 63305 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by transthoracic approach |
| 63306 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by thoracolumbar approach |
| 63307 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal approach |
63308Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; each additional segment (List separately in addition to codes for single segment)Spinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 25 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 64999 | Unlisted procedure, nervous system | Not Covered if used to report any procedure . . outlined in Coverage Limitations section | | CPT® Category Ill Code(s) | Description | Comments |
| 0274T | Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or ees ’ ectomy, t my / foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; cervical or thoracic | Not Covered |
| 0275T | Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or ees ’ ectomy, t my / foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar | Not Covered |
| HCPCS Code(s) | _ Description | Comments |
| C2614 | Probe, percutaneous lumbar discectomy | Not Covered |
| C9757 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and excision of herniated intervertebral disc, and repair of annular on ’ P defect with implantation of bone anchored annular closure device, including annular defect measurement, alignment and sizing assessment, and image guidance; 1 interspace, lumbar | Not Covered |
| Go276 | | Blinded procedure for lumbar stenosis, percutaneous image- uided lumbar decompression (PILD) or placebo-control ® P (PILD) or p , performed in an approved coverage with evidence development (CED) clinical trial | Not Covered |
S2350Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, single interspaceSpinal Decompression Surgery Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0483-030 Page: 26 of 36Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| Diskectomy, anterior, with decompression of spinal cord and/or |
| $2351 | nerve root(s), including osteophytectomy; lumbar, each |
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