Humana Discography Form

Description

Discography (also known as provocative discography) is an invasive diagnostic procedure to assess the structure of an intervertebral disc and determine if a specific disc is the cause of back pain. Discography is used in conjunction with other diagnostic imaging tests (e.g., computed tomography [CT] scan, magnetic resonance imaging [MRI]) when they have failed to give a definitive explanation for back pain.

Discography is performed by injecting radiographic contrast (dye) directly into the nucleus of the disc, which allows assessment of the integrity of the inner and outer annuli. It is theorized that if the disc is not intact, the nerve endings within the fibers of the discs will be directly stimulated, which will result in reproduction of the individual’s pain, further confirming the source of pain.

Discography Effective Date: 03/01/2023

Revision Date: 03/01/2023

Review Date: 03/01/2023

Policy Number: HUM-0480-015

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.

A variation of this procedure is functional anesthetic discography (FAD), during which a small catheter is inserted under fluoroscopic guidance and is temporarily sutured into place. The individual is then instructed to move about and undertake activity to reproduce the pain. An anesthetic medication is then injected into the suspect disc via the catheter. It is proposed that if the pain is relieved by the anesthetic, then the suspect disc is the source of the pain. (Refer to Coverage Limitations section)

Coverage Determination

Humana members may be eligible under the Plan for lumbar discography for evaluation of low back pain for the following indications:

• Suspected discogenic pain as the source of the back pain; OR
• Suspected failed back surgery, to distinguish between painful pseudoarthrosis, symptomatic disc in a previously posteriorly fused segment or recurrent disc herniation;

AND ALL of the following criteria are met:

• Other diagnostic tests (e.g., CT scan, MRI, myelography) have failed to provide definitive confirmation of the suspect disc as the source of pain; AND
• Persistent, severe pain of at least 6 months duration; AND
• Failure to improve after 12 weeks of conservative treatment under the direction of a healthcare professional, including ALL of the following:
• Activity/lifestyle modification; AND
• Medications (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs], non-narcotic analgesics) if medically appropriate and not contraindicated; AND
• Physical 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); AND
• Surgical intervention is planned/anticipated AND the procedure is not excluded in the Coverage Limitations section (for information regarding coverage determination/limitations for spinal surgery, please refer to Artificial Intervertebral Disc Replacement, Spinal Decompression Surgery or Spinal Fusion Surgery Medical Coverage Policies)

Coverage Limitations

Humana members may NOT be eligible under the Plan for lumbar discography for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate.

Please refer to the member's individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for lumbar discography when performed in conjunction with any procedure that has been determined by the Plan to be experimental or investigational including, but not limited to, the following:

• Annular (annulus) repair/closure including those performed with the Barricaid Anular Closure Device or the Discseel procedure (for information regarding coverage determination/limitations, please refer to Spinal Decompression Surgery Medical Coverage Policy); OR
• ANY percutaneous laminectomy, laminotomy, foraminectomy, foraminotomy, foraminolaminectomy, laminoplasty or corpectomy including, but may not be limited to, the MILD procedure (for information regarding coverage determination/limitations, please refer to Spinal Decompression Surgery Medical Coverage Policy); OR
• Automated percutaneous lumbar discectomy (APLD) (also known as automated percutaneous mechanical lumbar discectomy), including the Stryker Dekompressor Lumbar Discectomy System (for information regarding coverage determination/limitations, please refer to Spinal Decompression Surgery Medical Coverage Policy); OR

This (discography) is considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

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 any other type of discography including, but may not be limited to:

• Cervical discography; OR
• Functional anesthetic discography; OR
• Thoracic discography

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.

Humana members may NOT be eligible under the Plan for moderate sedation (regardless of whom administers it) or monitored anesthesia care (MAC) for discography, as standard medical practice consists of local anesthesia and slight sedation. This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Additional information about back pain and the spine may be found from the following websites: Background

• American Academy of Orthopaedic Surgeons
• National Institute of Neurological Disorders and Stroke
• National Library of Medicine
• North American Spine Society

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

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.

Brapny, 8 P interpretation Not Covered

Discography Effective Date: 03/01/2023

Revision Date: 03/01/2023

Review Date: 03/01/2023

Policy Number: HUM-0480-015

Page: 7 of 10Humana'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.

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age Not Covered if performed for discography

Discography Effective Date: 03/01/2023

Revision Date: 03/01/2023

Review Date: 03/01/2023

Policy Number: HUM-0480-015

Page: 8 of 10Humana'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.

cPT® Category Ill Code(s) Description Comments

No code(s) identified

HCPCS Code(s) Description Comments

References

American College of Radiology (ACR).

ACR Appropriateness Criteria. Cervical neck pain or cervical radiculopathy. https://www.acr.org. Published 1998. Updated 2018. Accessed February 10, 2023.

American College of Radiology (ACR). ACR Appropriateness Criteria. Low back pain. https://www.acr.org. Published 1996. Updated 2021. Accessed February 10, 2023.

American Society of Anesthesiologists (ASA). Distinguishing monitored anesthesia care (“MAC”) from moderate sedation/analgesia (conscious sedation). https://www.asahq.org. Published October 2004. Updated October 17, 2018. Accessed February 10, 2023.

American Society of Anesthesiologists (ASA). Expert Consensus Document. Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia. https://www.asahq.org. Published October 1999. Updated October 23, 2019. Accessed February 10, 2023.

American Society of Anesthesiologists (ASA). Position on monitored anesthesia care. https://www.asahq.org. Published October 25, 2005. Updated October 17, 2018. Accessed February 10, 2023.

American Society of Anesthesiologists (ASA). Statement on anesthetic care during interventional pain procedures for adults. https://www.asahq.org. Published October 22, 2005. Updated October 13, 2021. Accessed February 10, 2023.

American Society of Interventional Pain Physicians (ASIPP). Guideline. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. https://www.asipp.org. Published 2013. Accessed February 10, 2023.

Chou R, Loeser J, Owens D, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain – an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009;34:1066-1077.

Congress of Neurological Surgeons (CNS). AANS/CNS guideline update for performance of fusion procedures for degenerative disease of the lumbar spine. Part 6: discography for patient selection. https://www.cns.org. Published July 2014. Accessed February 10, 2023.

ECRI Institute. Evidence Report. Spinal fusion and discography for chronic low back pain and uncomplicated lumbar degenerative disc disease. https://www.ecri.org. Published October 19, 2007. Accessed February 1, 2023.

ECRI Institute. Hotline Response (ARCHIVED). Discography for diagnosing chronic low back pain and uncomplicated lumbar degenerative disc disease. https://www.ecri.org. Published April 7, 2004. Updated March 27, 2012. Accessed February 1, 2023.

ECRI Institute. Product Brief (ARCHIVED). Discyphor Catheter System (Kyphon/Medtronic) for functional anesthetic discography. https://www.ecri.org. Published June 16, 2014. Accessed February 1, 2023.

Hayes, Inc. Medical Technology Directory (ARCHIVED). The clinical utility of lumbar discography for assessing low back pain: impact on patient management and health outcomes. https://evidence.hayesinc.com. Published September 7, 2017. Updated October 11, 2021. Accessed February 1, 2023.

Hayes, Inc. Search & Summary (ARCHIVED). Cervical discography as a diagnostic test for neck pain. https://evidence.hayesinc.com. Published October 12, 2017. Accessed January 21, 2019.

Discography Effective Date: 03/01/2023

Revision Date: 03/01/2023

Review Date: 03/01/2023

Policy Number: HUM-0480-015

Page: 9 of 10Humana'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.

Discography Effective Date: 03/01/2023

Revision Date: 03/01/2023

Review Date: 03/01/2023

Policy Number: HUM-0480-015

Page: 10 of 10Humana'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.

15. Hayes, Inc. Search & Summary (ARCHIVED). Thoracic discography as a diagnostic test for thoracic back pain. https://evidence.hayesinc.com. Published October 19, 2017. Accessed January 21, 2019.
16. Manchikanti L, Soin A, Benyamin R, et al. An update of the systematic appraisal of the accuracy and utility of discography in chronic spinal pain. Pain Physician. 2018;21:91-110.
17. MCG Health. Diskography (discography). 26th edition. https://www.mcg.com. Accessed December 16, 2022.
18. North American Spine Society (NASS). Coverage Policy Recommendations. Discography. https://www.spine.org. Published October 2019. Accessed February 10, 2023.
19. North American Spine Society (NASS). Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care. Diagnosis and treatment of low back pain. https://www.spine.org. Published January 2020. Accessed February 10, 2023.
20. UpToDate, Inc. Acute lumbosacral radiculopathy: pathophysiology, clinical features, and diagnosis. https://www.uptodate.com. Updated January 2023. Accessed February 10, 2023.
21. UpToDate, Inc. Subacute and chronic low back pain: nonsurgical interventional treatment. https://www.uptodate.com. Updated January 2023. Accessed February 10, 2023.
22. UpToDate, Inc. Subacute and chronic low back pain: surgical treatment. https://www.uptodate.com. Updated February 7, 2023. Accessed February 10, 2023.
23. UpToDate, Inc. Vertebral osteomyelitis and discitis in adults. https://www.uptodate.com. Updated January 2023. Accessed February 10, 2023.