Table of Contents

Provider Claim Codes Section Title

• 27599, O565T, OS66T, 0717T, 0718T Autologous Cellular Implant Derived From Adipose Tissue
• 62244, 62263 Epidural Lysis of Adhesions
• 64999 Hydrodissection
• 95919 Quantitative Pupillometry
• 0533T, 0534T, 0535T, 0536T Continuous Recording for Movement Disorders
• 0594T Intramedullary Lengthening Devices-Humerus
• O609T, 0610T, 0611T, 0612T Magnetic Resonance Spectroscopy for Discogenic Pain
• 0615T Eye Movement Analysis Without Spatial Calibration for Concussion
• 0639T Wireless Skin Sensor for Cerebrospinal Fluid Shunt Flow
• 0693T Computerized Markerless Kinetic Motion Analysis
• o776T Localized Therapeutic Hypothermia for Mild Traumatic Brain Injuries
• 0778T Surface Mechanomyography Musculoskeletal Diagnostic System
• C1834 Continuous Compartmental Pressure Monitor

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Code Compendium (Musculoskeletal and Neurologic)

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E0734. A4542 External Upper Limb Tremor Stimulator of the Wrist

M0076 Prolotherapy for Musculoskeletal Indications

Autologous Cellular Implant Derived from Adipose Tissue

Section Effective Date: 02/02/2023

Section Revision Date: 02/02/2023

Section Review Date: 02/02/2023

Updated References

Not Covered if used to report autologous adipose derived microfragmented stem cell implant/therapy

27599 Unlisted procedure, femur or knee autologous adipose derived microfragmented stem cell implant/therapy Not Covered

O565T Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation Not Covered

O566T Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation; injection of cellular implant into knee joint including ultrasound guidance, unilateral Not Covered

0717T Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; adipose tissue harvesting, isolation and preparation of harvested cells, including incubation with cell dissociation enzymes, filtration, washing and concentration of ADRCs Not Covered

0718T Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; adipose tissue harvesting, isolation and preparation of harvested cells, including incubation with cell dissociation enzymes, filtration, washing and concentration of ADRCs; Not Covered

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injection into supraspinatus tendon including ultrasound guidance, unilateral Autologous cellular implant derived from adipose tissue, also referred to as autologous adipose-derived regenerative cell therapy, autologous microfragmented adipose injection or Lipogems, is in the treatment of musculoskeletal conditions such as degenerative joint disease, osteoarthritis or rotator cuff tears. The procedure involves injecting mesenchymal stem cells (MSCs) into an impacted joint (eg, knee, shoulder) purportedly to aid tissue healing and regeneration. Adipose tissue is a desirable source of MSCs due to large quantities of MSCs found in the tissue, the abundance of adipose tissue and ease of collection.

MSC collection occurs by harvesting lipoaspirate through liposuction followed by microfragmentation. Microfragmentation is a closed loop system that separates adipose tissue from proinflammatory blood and oil residue by filtering and mechanical agitation. The remaining microfragmented adipose tissue is assumed to maintain pericytes which are a source of MSCs. An example of a US Food & Drug Administration (FDA) approved device for processing lipoaspirated adipose tissue is the Lipogems system. Following microfragmentation, MSCs are injected intraarticularly into the donor under local anesthetic. Ultrasound guidance may be used in conjunction with the procedure when performed alone or the procedure may be an adjuvant to arthroscopy. The Transpose Ultra system is currently under investigation for the use to treat rotator cuff tendinopathy. (Refer to Coverage Limitations section)

For information regarding adipose tissue-derived stem cells therapy and fecal incontinence treatments, please refer to Fecal Incontinence Evaluation and Treatments Medical Coverage Policy.

For information regarding autologous adipose-derived regenerative cell therapy (ADRC) and cosmetic surgery, please refer to Cosmetic and Reconstructive Surgery Medical Coverage Policy.

Humana members may NOT be eligible under the Plan for autologous cellular implant derived from adipose tissue, autologous adipose derived regenerative cell therapy, autologous microfragmented adipose injection or Lipogems for any musculoskeletal indication. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as Code Compendium (Musculoskeletal and Neurologic) Policy Number: HUM-0584-011 Page: 4 of 27 Humana'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.

References

• American College of Rheumatology (ACR). 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip and knee. https://www.rheumatology.org. Published February 2020. Accessed December 21, 2022.
• ECRI Institute. Clinical Evidence Assessment. Autologous mesenchymal stem cell therapy for chronic knee and ankle pain from osteoarthritis. https://www.ecri.org. Published October 15, 2019. Updated January 26, 2022. Accessed December 21, 2022.
• ECRI Institute. Product Brief. Lipogems system (Lipogems International) for processing lipoaspirated adipose tissue. https://www.ecri.org. Published October 23, 2017. Accessed December 3, 2020.
• ECRI Institute. Product Brief. Lipografter (Musculoskeletal Transplant Foundation) for autologous fat tissue collection. https://www.ecri.org. Published April 1, 2019. Accessed December 28, 2021.
• Hayes, Inc. Emerging Technology Report. Transpose Ultra system for rotator cuff tendinopathy. https://evidence.hayesinc.com.

References

• Hayes, Inc. Health Technology Assessment. Autologous microfragmented adipose tissue injection for treatment of osteoarthritis. https://evidence.hayesinc.com. Published March 11, 2020. Updated February 28, 2022. Accessed December 22, 2022.
• UpToDate, Inc. Management of knee osteoarthritis. https://www.uptodate.com. Updated November 2022. Accessed December 22, 2022.
• US Department of Veterans Affairs (VA). VA/DoD Clinical Practice Guideline. The nonsurgical management of hip & knee osteoarthritis. https://www.va.gov. Published July 2020. Accessed December 22, 2022.
• US Food & Drug Administration (FDA). 510(k) summary: Lipogems system. https://www.fda.gov. Published May 18, 2017. Accessed December 5, 2019.

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Epidural Lysis of Adhesions

Section Effective Date: 02/02/2023

Section Revision Date: 02/02/2023

Section Review Date: 02/02/2023

Updated References

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 Not Covered

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 Not Covered

Epidural lysis of adhesions is a pain management procedure that has been proposed as a method to relieve chronic back pain. This procedure may also be known as adhesiolysis, endoscopic adhesiolysis, epidurolysis, percutaneous adhesiolysis or percutaneous epidural neuroplasty. It differs from epidural injections as it attempts to treat the neural (nerve) adhesions that purportedly cause the pain.

Epidural lysis of adhesions can be performed by use of a fiberoptic endoscope (epiduroscopy), percutaneously with the use of a catheter (flexible tube) or with the more specialized Racz catheter. In epiduroscopy, normal saline is injected into the sacral canal to distend and decompress the epidural space; purportedly the fiberoptic endoscope can then directly disrupt the fibrosis, scar tissue or adhesions. This procedure is generally performed in an outpatient setting, utilizing local anesthesia and light sedation.

In the percutaneous procedure utilizing the Racz catheter, the specialized epidural catheter is inserted under fluoroscopy via the sacral canal. The injection of dye (an epidurogram) may indicate the area of adhesions and provide a way to perform lesion-specific lysis utilizing the flexible wire embedded catheter. Local anesthetic, corticosteroid and hypertonic sodium chloride solution injections via the catheter are performed daily for 3 days. During this time the catheter is left in place and the individual is generally hospitalized.

A similar version of the procedure involves a single use catheter (instead of the Racz catheter) which is removed after the lysis is completed.

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The procedure may be repeated at a later date, but would require a new catheter placement.

Humana members may NOT be eligible under the Plan for epidural lysis of adhesions. 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.

References

• Hayes, Inc. Health Technology Assessment (ARCHIVED). Endoscopic epidural adhesiolysis for chronic back pain. https://evidence.hayesinc.com. Published December 23, 2013. Updated December 14, 2015. Accessed December 23, 2022.
• Hayes, Inc. Medical Technology Directory. Percutaneous epidural adhesiolysis for chronic low back pain. https://evidence.hayesinc.com. Published September 27, 2018. Updated October 24, 2022. Accessed December 23, 2022.
• Helm S, Hayek S, Colson J, et al. Spinal endoscopic adhesiolysis in post lumbar surgery syndrome: an update of the assessment of the evidence. Pain Physician. 2013;16:SE125-SE150.
• Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. American Society of Interventional Pain Physicians (ASIPP). Pain Physician. 2013;16:S49-S283.

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UpToDate, Inc. Subacute and chronic low back pain: surgical treatment. https://www.uptodate.com. Updated November 2, 2022. Accessed December 29, 2022.

Hydrodissection

Effective Date: 02/02/2023

Revision Date: 02/02/2023

Review Date: 02/02/2023

Updated References

Hydrodissection is the injection of fluids, usually normal saline, through a peripheral nerve block needle to help release entrapped nerves by moving but not completely releasing the fascia, ligaments or tendons surrounding a nerve to treat neurologic and musculoskeletal conditions. Purportedly, the movement may disrupt adhesions and alleviate inflammation.

Humana members may NOT be eligible under the Plan for hydrodissection for any musculoskeletal or neurologic indication. 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.

References

• Cass S. Ultrasound-guided nerve hydrodissection: what is it? a review of the literature. Current Sports Medicine Reports. 2016;15(1):20-22. https://journals.lww.com. Accessed December 29, 2022.
• ECRI Institute. Hotline Response. Hydrodissection for treating entrapment neuropathies. https://www.ecri.org. Published July 1, 2016. Updated January 28, 2020. Accessed December 30, 2022.
• ECRI Institute. Hotline Response. Hydrodissection for treating pain from musculoskeletal conditions. https://www.ecri.org. Published January 28, 2020. Accessed December 30, 2022.
• Hayes, Inc. Evidence Analysis Research Brief. Hydrodissection for treatment of neuropathic pain. https://evidence.hayesinc.com. Published January 12, 2023. Accessed January 13, 2023.
• UpToDate, Inc. Ultrasound for peripheral nerve block. https://www.uptodate.com.

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Quantitative Pupillometry

Section Effective Date: 02/02/2023

Section Revision Date: N/A

Section Review Date: 02/02/2023

New Policy

Not Covered

Pupil evaluation is part of a neurological exam with abnormalities in pupillary responses being associated with neurological deterioration. The pupil light reflex (PLR), controlled by the autonomic nervous system, refers to a change in pupil size or diameter in response to light. In addition to PLR, pupillary examination includes evaluating the pupils for equal size, round shape and the ability to focus on near or distant objects. This assessment routinely involves the use of a handheld light source (penlight) with the clinician subjectively evaluating the pupils based on their experience, skill and technique.

Quantitative pupillometry refers to an objective way of measuring the diameter of the pupil. Using automated infrared light, the pupillometer obtains objective quantitative measurements including size, asymmetry, constriction related to light exposure. latency, constriction velocity, and dilation velocity.2 The NPi-200 and NPi-300 are examples of automated pupillometers.

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Humana members may NOT be eligible under the Plan for quantitative pupillometry for neurological assessment or any indication. 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.

References

• ECRI Institute. Product Brief. NPi-200 pupillometer (NeurOptics, Inc.) for measuring pupil size and reactivity. https://www.ecri.org. Published July 2018. Accessed December 16, 2022.
• Hayes, Inc. Clinical Research Response. Automated pupillometry for detection of impending brain herniation in patients with acute neurological injury. https://evidence.hayesinc.com. Published December 27, 2021. Accessed December 16, 2022.

Continuous Recording for Movement Disorders

Section Effective Date: 06/22/2023

Section Revision Date: 06/22/2023

Section Review Date: 02/02/2023

Updated Description, References

Description

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• symptoms, including bradykinesia, dyskinesia, Covered
• 36T and tremor for 6 days up to 10 days; download review, interpretation and report Not

Movement disorders are neurological conditions that cause an individual to have abnormal voluntary or involuntary movements. These chronic disorders are often characterized by bradykinesia, dyskinesia and tremors which cause activities of daily living, ambulation and other tasks to be progressively more difficult.

There are medications and other therapies to help aid in the treatment of these disabling symptoms. However, motor and nonmotor variations in movement disorders, such as Parkinson's disease, are sometimes difficult to evaluate or quantify. One suggested method for objectively measuring these fluctuations is via a wearable technology that provides continuous and ambulatory assessment of motor complications. Examples of US Food & Drug Administration (FDA) approved continuous recorders include the following:

• NeuroRPM \'96 a software application for the Apple Watch that is prescribed by a health professional to quantify motor disorder symptoms during wake periods in an individual 46 to 85 years of age. NeuroRPM collects accelerometer and gyroscope algorithm data from the Apple Watch using machine learning. NeuroRPM is intended for clinic and home environments.4
• Personal KinetiGraph (PKG) system \'96 a wrist-worn recording device that utilizes proprietary algorithms to quantify movement disorder symptoms which purportedly provides a measure of the severity and proportion of time spent at various levels of dyskinesia and bradykinesia in relation to the timing of medications.

Humana members may NOT be eligible under the Plan for continuous recording of movement disorder symptoms (eg, NeuroRPM, Personal KinetiGraph [PKG]). This technology 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.

References

• Farzanehfar P, Woodrow H, Braybrook M, et al. Objective measurement in routine care of people with Parkinson's disease improves outcomes. NPJ Parkinsons Dis. 2018;4(10)1-8. https://www.nature.com/npjparkd. Accessed January 3, 2023.
• Hayes, Inc. Search & Summary (ARCHIVED). Personal KinetiGraph (PKG) System (Global Kinetics Corp) for management of Parkinson's disease. https://evidence.hayesinc.com. Published December 18, 2018. Accessed December 4, 2020.
• Odin P, Chaudhuri KR, Volkmann J, et al. Viewpoint and practical recommendations from a movement disorder specialist panel on objective measurement in the clinical management of Parkinson's disease. NPJ Parkinsons Dis. 2018;4(14)1-7. https://www.nature.com/npjparkd. Accessed January 3, 2023.
• US Food & Drug Administration (FDA). 510(k) summary: NeuroRPM. https://www.fda.gov. Published March 17, 2023. Accessed June 1, 2023.
• US Food & Drug Administration (FDA). 510(k) summary: Personal Kinetigraph (PKG) System. https://www.fda.gov. Published September 20, 2016.

Intramedullary Lengthening Devices – Humerus

Section Effective Date: 06/22/2023

Section Revision Date: 06/22/2023

Section Review Date: 06/22/2023

Updated References

Osteotomy, humerus with insertion of an intramedullary lengthening device, including intraoperative imaging, initial insertion. Not Covered

Limb lengthening is a procedure to lengthen bones in the arms (humerus, radius, ulna) and legs (femur, tibia) in a gradual process. Intramedullary lengthening devices are inserted internally into the marrow cavity of a bone and are used as an alternative to external fixator lengthening devices. An osteotomy is performed to cut the bone to create two separate pieces prior to attaching or inserting a lengthening device.

Intramedullary lengthening systems consist of a telescoping metal rod or a lengthening nail with a magnetic motor contained internally and an external remote controller (ERC) that makes the nail slowly lengthen, therefore lengthening the bone. The ERC is programmed by the physician to lengthen the limb while at home. An example of an US Food & Drug Administration (FDA) approved intramedullary lengthening device is the PRECICE indicated for long bones.

Humana members may NOT be eligible under the Plan for humerus intramedullary lengthening devices (eg, PRECICE). 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.

References

• ECRI Institute. Clinical Evidence Assessment. Intramedullary devices for lengthening the humerus. https://www.ecri.org. Published June 10, 2020. Accessed May 18, 2023.
• US Food & Drug Administration (FDA). 510(k) summary: PRECICE bone transport system. https://www.fda.gov. Published February 5, 2019. Accessed June 1, 2020.

Magnetic Resonance Spectroscopy for Discogenic Pain

Section Effective Date: 06/22/2023

Section Revision Date: 06/22/2023

Section Review Date: 06/22/2023

Updated References

Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); acquisition of single voxel data, per disc, on biomarkers (ie, lactic acid, carbohydrate, alanine, laal, propionic acid), O609T. Not Covered

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• 0610T Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); transmission of biomarker data for software analysis Not Covered
• 0611T Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); postprocessing for algorithmic analysis of biomarker data for determination of relative chemical differences between discs Not Covered
• 0612T Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); interpretation and report Not Covered

Magnetic resonance spectroscopy (MRS) is a noninvasive diagnostic test that combines magnetic resonance imaging (MRI) for anatomical location and spectroscopy for analysis. Spectroscopy is a series of tests that measure and analyze biochemical changes or biomarkers in human tissues. Purportedly, an MRS can be used to identify lumbar discs for discogenic pain by measuring the biomarkers of acidity (alanine, lactic acid, propionic acid) and disc structure (collagen, proteoglycan).

Humana members may NOT be eligible under the Plan for magnetic resonance spectroscopy for discogenic pain. 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.

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Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

References

• Gornet MG, Peacock J, Claude J, et al. Magnetic resonance spectroscopy (MRS) can identify painful lumbar discs and may facilitate improved clinical outcomes of lumbar surgeries for discogenic pain. Eur Spine J. 2019;28(4):674-687. https://link.springer.com. Accessed May 18, 2023.
• MCG Health. Magnetic resonance spectroscopy. 26th edition. https://www.mcg.com. Accessed May 24, 2023.

Eye Movement Analysis Without Spatial Calibration for Concussion

Section Effective Date: 06/22/2023

Section Revision Date: 06/22/2023

Section Review Date: 06/22/2023

Updated Description, References

Description

0615T Eye-movement analysis without spatial calibration, with interpretation and report Not Covered

Eye movement analysis without spatial calibration is intended as an assessment aid in the diagnosis of concussion that tracks eye movements to provide interpretation of the functional condition of the brain.

The EyeBOX system consists of a computer program for analysis of eye movements, eye tracking camera, video stimulus display screen and integrated stand. The system measures gaze while calculating a score based on a 0-20 scale. Values of ten or more provide a positive classification that may correspond in individuals with or without a concussion while values of under ten provides a negative classification that corresponds with a lack of a concussion. The assessment is to occur within 1 week of the head injury in an individual 5 through 67 years of age along with a standard neurological assessment of a concussion.

The EYE-SYNC system is intended to record, measure and analyze eye movements within 3 days of a sport-related head injury in an individual 17-24 years of age in conjunction with a standard neurological assessment, for use by medical professionals qualified to interpret the results of a concussion assessment examination.

The system consists of a virtual reality technology headset containing 2 eye tracking sensor cameras and a display device. The eye tracking device Code Compendium (Musculoskeletal and Neurologic) Policy Number: HUM-0584-011 Page: 15 of 27 Humana'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. communicates over Bluetooth wireless to an administrative tablet for control and data exchange. Proprietary analysis is done via a software app.⁸

Humana members may NOT be eligible under the Plan for eye movement analysis without spatial calibration (eg, EyeBOX, EYE-SYNC). 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.

References

• American Academy of Neurology (AAN). Summary of evidence based guideline update: evaluation and management of concussion in sports. https://www.aan.com. Published March 2013. Updated April 30, 2022. Accessed June 2, 2023.
• ECRI Institute. Clinical Evidence Assessment. EyeBox (Oculogica, Inc.) for aiding diagnosis of concussion. https://www.ecri.org. Published June 10, 2020. Accessed June 1, 2023.
• Hayes, Inc. Evidence Analysis Research Brief. EyeBox (Oculogica) as an aid for diagnosis of discussion. https://evidence.hayesinc.com. Published May 9, 2023. Accessed June 1, 2023.
• UpToDate, Inc. Acute mild traumatic brain injury (concussion) in adults. https://www.uptodate.com. Updated April 2023. Accessed June 1, 2023.
• UpToDate, Inc. Concussion in children and adolescents: clinical manifestation and diagnosis. https://www.uptodate.com. Updated April 19, 2022. Accessed June 1, 2022.
• US Department of Veterans Affairs (VA). VA/DoD Clinical Practice Guideline. The management and rehabilitation of post-acute mild traumatic brain injury. https://www.va.gov. Published June 2021. Accessed June 1, 2023.
• US Food & Drug Administration (FDA). De novo summary: EyeBOX device. https://www.fda.gov. Published June 18, 2015. Accessed May 20, 2020.
• US Food & Drug Administration (FDA). 510(k) summary: EYE-SYNC. https://www.fda.gov. Published October 2, 2021. Accessed June 1, 2023.

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Wireless Skin Sensor for Cerebrospinal Fluid Shunt Flow

Section Effective Date: 02/02/2023

Section Revision Date: 02/02/2023

Section Review Date: 02/02/2023

Updated References

A wireless skin sensor or a wearable shunt monitor is used to manage hydrocephalus by measuring the flow of cerebrospinal fluid (CSF) through a surgically implanted shunt. The soft, flexible sensor, placed on the skin over the location of the shunt in the neck, measures temperature and heat transfer to determine if CSF is draining and at what amount. The sensor has wireless technology to be able to deliver the measurement readings to mobile communication devices such as smartphones.

Currently, there is no US Food & Drug Administration (FDA) approved wireless skin sensor monitor for CSF shunt flow.

Humana members may NOT be eligible under the Plan for wireless skin sensor for cerebrospinal fluid shunt flow. 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.

References

• Hayes, Inc. Emerging Technology Report. FlowSense device for evaluation of ventricular shunt function. https://evidence.hayesinc.com. Published November 23, 2022. Accessed January 3, 2023.
• Hayes, Inc. Evidence Analysis Research Brief (ARCHIVED). Noninvasive wireless thermal flow sensor for assessment of ventriculoperitoneal shunt patency in patients with hydrocephalus. https://evidence.hayesinc.com. Published January 22, 2021. Accessed January 3, 2023.
• Krishnan S, Ray, T, Ayer A, et al. Epidermal electronics for noninvasive, wireless, quantitative assessment of ventricular shunt function in patients with hydrocephalus. Sci Transl Med. 2018;10(465):1-13. https://stm.sciencemag.org. Accessed January 3, 2023.

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Computerized Markerless Kinetic Motion Analysis

Section Effective Date: 02/02/2023

Section Revision Date: 02/02/2023

Section Review Date: 02/02/2023

Updated References

Not Covered

A computer and 3D video system are used to quantify and graphically display human movement patterns and techniques without the use of markers, sensors or force plates. Purported uses include Parkinson’s disease, pre/post-surgical rehabilitation for orthopedic procedures and physical therapy for performance issues. An example of an US Food & Drug Administration (FDA) approved computerized markerless kinetic motion analysis system is the DARI Motion.

Humana members may NOT be eligible under the Plan for computerized markerless kinetic motion analysis (eg, DARI Motion). 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.

References

• Hayes, Inc. Evidence Analysis Research Brief (ARCHIVED). DARI motion markerless 3D motion capture and analysis system for Parkinson disease. https://evidence.hayesinc.com. Published November 17, 2021. Accessed January 3, 2023.
• US Food & Drug Administration (FDA). 510(k) summary: DARI Health. https://www.fda.gov. Published March 7, 2019.

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Localized Therapeutic Hypothermia for Mild Traumatic Brain Injuries

Section Effective Date: 12/08/2022

Section Revision Date: N/A

Section Review Date: 12/08/2022

New Policy

Localized therapeutic hypothermia therapy is currently under investigation for the treatment of mild traumatic brain injury (also referred to as a concussion). A portable cooling device (eg, pro2cool device) consists of control unit and a soft garment that is wrapped around the individual’s head and neck. A fluid mixture of isopropyl alcohol and water circulates within the unit to provide cooling to the carotid arteries therefore decreasing the temperature of the blood before it reaches the brain.

Humana members may NOT be eligible under the Plan for localized therapeutic induction of intra-brain hypothermia (eg, pro2cool device). 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.

References

• Brain Trauma Foundation. Guidelines for the management of pediatric severe traumatic brain injury, 3rd edition: update of the Brain Trauma Foundation guidelines. https://www.braintrauma.org. Published March 2019. Accessed January 5, 2022.
• Brain Trauma Foundation. Guidelines for the management of severe traumatic brain injury, 4th edition. https://www.braintrauma.org. Published September 2016. Accessed October 25, 2022.
• Hayes, Inc. Emerging Technology Report. pro2cool (TecTraum) for mild traumatic brain injury. https://evidence.hayesinc.com. Published July 29, 2022. Accessed October 25, 2022.
• UpToDate, Inc. Acute mild traumatic brain injury (concussion) in adults. https://www.uptodate.com. Updated September 2022. Accessed October 26, 2022.
• UpToDate, Inc. Concussion in children and adolescents: management. https://www.uptodate.com. Updated September 8, 2022. Accessed October 26, 2022.

Code Compendium (Musculoskeletal and Neurologic) Policy Number: HUM-0584-011 Page: 19 of 27

Humana'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.

Surface Mechanomyography Musculoskeletal Diagnostic System

Section Effective Date: 12/08/2022

Section Revision Date: N/A

Section Review Date: 12/08/2022

New Policy

Surface mechanomyography (sMMG) combined with inertial measurement unit (IMU) sensors are being investigated as a potential diagnostic tool for musculoskeletal and orthopedic conditions such as the source for injury or pain. The sensors are placed on the skin across the muscles in the area of concern to measure muscle performance to assist in evaluation of gait, joint function or posture abnormalities.

Some clinical applications of sMMG include assessing progress during physical therapy/rehabilitation following a musculoskeletal injury or surgery; evaluating muscular function and fatigue in those with muscular disease or atrophy; and assisting with evaluation of neuromuscular function in poststroke individuals, patients with spinal cord injuries, and patients with neuromuscular limitations who require a prosthetic device or other assistive technologies.¹

Humana members may NOT be eligible under the Plan for a surface mechanomyography diagnostic system. 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.

References

• Hayes, Inc. Evidence Analysis Research Brief. Surface mechanomyography for measurement of gait, posture and joint function for musculoskeletal conditions. https://evidence.hayesinc.com. Published November 9, 2022. Accessed November 17, 2022.

Continuous Compartmental Pressure Monitor

Section Effective Date: 06/22/2023

Section Revision Date: 06/22/2023

Section Review Date: 06/22/2023

Updated References

A continuous compartmental pressure monitor is an implantable device that purportedly aids in the diagnosis of acute compartment syndrome (ACS) by providing continuous real-time monitoring of intracompartmental muscle pressure. ACS may develop after significant trauma particularly with long bone fractures. The system consists of an introducer, pressure censor and an LCD display. An example of an US Food & Drug Administration (FDA) approved continuous compartmental pressure monitor is the MY01.

Humana members may NOT be eligible under the Plan for a continuous compartmental pressure monitor (eg, MY01). 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.

References

• ECRI Institute. Clinical Evidence Assessment. MY01 continuous compartmental pressure monitor (MY01, Inc.) for aiding in the diagnosis of compartmental syndrome. https://www.ecri.org. Published October 1, 2020. Updated April 27, 2022. Accessed May 30, 2023.
• UpToDate, Inc. Acute compartment syndrome of the extremities. https://www.uptodate.com. Updated April 2023. Accessed May 30, 2023.
• US Food & Drug Administration (FDA). 510(k) summary: MY01 continuous compartmental pressure monitor. https://www.fda.gov. Published July 30, 2022.

Code Compendium (Musculoskeletal and Neurologic)

Policy Number: HUM-0584-011 Page: 21 of 27

Humana'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.

External Upper Limb Tremor Stimulator of the Wrist

Section Effective Date: 01/01/2024

Section Revision Date: 12/14/2023

Section Review Date: 12/14/2023

Updated Provider Claims Codes

External upper limb stimulators, also referred to as transcutaneous afferent patterned stimulation (TAPS), are wrist-worn noninvasive neuromodulation devices delivering peripheral nerve stimulation to the median and radial nerves purportedly providing aid in the transient relief of hand tremors. Stimulation is calibrated according to the individual's tremor frequency. The device consists of a stimulator, wrist band and a magnetic charging base. An example of an US Food & Drug Administration (FDA) approved external upper limb tremor stimulator for the treatment of essential tremor is the Cala ONE also known as Cala Trio.

Humana members may NOT be eligible under the Plan for external upper limb tremor stimulator of the peripheral nerves of the wrist. 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.

References

1. ECRI Institute. Clinical Evidence Assessment. Cala Trio wrist-worn neuromodulation therapy (Cala Health, Inc.) https://www.ecri.org. Published January 13, 2022. Updated January 19, 2023. Accessed June 1, 2023.
2. Hayes, Inc. Evolving Evidence Review. Cala Trio (Cala Health, Inc.) for treatment of essential tremor. https://evidence.hayesinc.com. Published January 5, 2022. Updated May 2, 2023. Accessed June 1, 2023.
3. Isaacson S, Peckham E, Tse W, et al. Prospective home-use study on non-invasive neuromodulation therapy for essential tremor. Tremor and Other Hyperkinetic Movements. 2020;10(1):1-16. https://digitalcommons.psjhealth.org. Accessed June 1, 2023.
4. Kim J, Wichmann T, Inan O, et al. A wearable system for attenuating essential tremor based on peripheral nerve stimulation. IEEE J Transl Eng Health Med. 2020;8:1-11. https://www.embs.org. Accessed June 1, 2023.
5. UpToDate, Inc. Essential tremor: treatment and prognosis. https://www.uptodate.com. Updated April 2023. Accessed June 1, 2023.
6. US Food & Drug Administration (FDA). De novo summary: Cala ONE https://www.fda.gov. Published April 26, 2018. Accessed March 15, 2021.

Code Compendium (Musculoskeletal and Neurologic) Policy Number: HUM-0584-011 Page: 22 of 27

Humana'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.

Prolotherapy for Musculoskeletal Indications

Section Effective Date: 06/22/2023

Section Revision Date: 06/22/2023

Section Review Date: 06/22/2023

Updated References

M0076 Prolotherapy Not Covered

Code Compendium (Musculoskeletal and Neurologic) Policy Number: HUM-0584-011 Page: 23 of 27

Prolotherapy is a pain management treatment that involves injecting a sclerosant (irritant) solution into the region of joints, muscles or ligaments that are thought to cause chronic low back or joint pain (as is commonly seen in arthritis).

Humana'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.

Prolotherapy, also known as reconstructive ligament therapy or joint sclerotherapy, may be used in an attempt to invoke the body’s natural inflammatory response purportedly promoting new collagen growth to increase/improve joint stability or muscle regeneration/strengthening. Examples of injection solutions include, but may not be limited to, sodium morrhuate, dextrose (D50), glycerine, zinc sulfate, fibrin glue or platelet rich plasma (PRP) and often includes an anesthetic agent, such as lidocaine.

For information regarding PRP, please refer to the Bone Graft Substitutes Medical Coverage Policy.

Prolotherapy may be excluded by certificate. Please consult the member’s individual certificate regarding Plan coverage.

Humana members may NOT be eligible under the Plan for prolotherapy for musculoskeletal indications as this treatment is generally excluded by certificate.

For those Plans that do not specifically exclude prolotherapy, 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.

Note: The criteria for prolotherapy are consistent with the Medicare National Coverage Policy and therefore apply to Medicare members.

References

• Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Prolotherapy, joint sclerotherapy and ligamentous injections with sclerosing agents (150.7). https://www.cms.gov. Published September 27, 1999. Accessed May 30, 2023.
• Hayes, Inc. Medical Technology Directory (ARCHIVED). Prolotherapy for treatment of joint and ligamentous conditions. https://evidence.hayesinc.com. Published August 8, 2008. Updated July 23, 2012. Accessed May 30, 2023.

Code Compendium (Musculoskeletal and Neurologic)

Policy Number: HUM-0584-011 Page: 24 of 27

Humana'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.

UpToDate, Inc. Overview of the management of overuse (persistent) tendinopathy. https://www.uptodate.com. Updated April 2023. Accessed May 30, 2023.

UpToDate, Inc. Subacute and chronic low back pain: nonsurgical interventional treatment. https://www.uptodate.com. Updated April 2023. Accessed May 30, 2023.

Provider Claims Codes

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.

Code Compendium (Musculoskeletal and Neurologic) Policy Number: HUM-0584-011 Page: 25 of 27

Humana'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.

Code Compendium (Musculoskeletal and Neurologic) Policy Number: HUM-0584-011 Page: 26 of 27

Humana'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.

0778T Surface mechanomyography (sMMG) with concurrent application of inertial measurement unit (IMU) sensors for measurement of multi-joint range of motion, posture, gait, and muscle function Not Covered HCPCS Code(s) Description Comments

Code Compendium (Musculoskeletal and Neurologic) Policy Number: HUM-0584-011 Page: 27 of 27 Humana'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.