Humana Spinal Decompression Surgery - Medicare Advantage Form

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Jurisdiction

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• Percutaneous Image-guided

Description

Spinal 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.

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 a 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.

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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 spinal 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.
• 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.
• 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 purportedly decompress a herniated disc. Laser discectomy may be performed either laparoscopically or percutaneously.
• 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.
• 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.

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.

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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).

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.

Coverage Determination

Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare.

In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the following criteria:

Spinal Decompression Surgery

The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy.

In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider MCG Guidelines.

Coverage Limitations

US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage