HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-254-001
Topic:
Lumbar Decompression
Section:
Surgery
Effective Date:
October 1, 2018
Issued Date:
October 1, 2018
Last Revision Date:
September 2018
Annual Review:
April 2018
 
 

Decompression is a surgical procedure that is performed to alleviate pain caused by pinched nerves (neural impingement).

During a lumbar decompression back surgery, a small portion of the bone over the nerve root and/or disc material from under the nerve root is removed to give the nerve root more space and provide a better healing environment.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

Initial primary lumbar decompression may be considered medically necessary when the following criteria are met:

  • The individual is diagnosed with spinal stenosis/spondylolisthesis with neurogenic claudication secondary to central/lateral recess/foraminal Stenosis and ALL of the following:
    • Subjective symptoms consistent with recent (within 6 months) MRI/CT findings and any ONE of the following:
      • Radiating dermatomal pain into buttock(s) and/or lower extremity(ies); or
      • Symptoms worsen with standing and/or walking; or
      • Symptoms are alleviated with sitting and/or forward flexion; and
    • Objective physical findings consistent with recent (within 6 months) MRI/CT; and
    • Less than clinically meaningful improvement from epidural steroid injections/selective nerve root block; or
  • The individual is diagnosed with spondylolisthesis and has back pain, neurogenic claudication symptoms or radicular pain from lateral recess, or foraminal stenosis on recent (within 6 months) MRI/CT associated with BOTH of the following:
    • Significant functional impairment; and
    • Listhesis demonstrated on plain x-rays; or
  • The individual has Spinal stenosis/Spondylolisthesis symptoms that are severe and disabling or unresponsive to six (6) weeks of conservative care as evidenced by EITHER of the following:
    • Less than clinically meaningful improvement* from prescription strength analgesics, steroids, and/or NSAIDs for six (6) weeks; or
    • Less than clinically meaningful improvement* from a provider directed program prescribed by a physical therapist, chiropractic provider, osteopathic or allopathic physician for six (6) weeks; or
  • A Recent (within 6 months) MRI/CT identifies nerve root impingement and/or thecal sac impingement caused by stenosis/lithesis that correlates with patient symptoms or physical findings; and
  • No previous surgeries at the level(s) involved; and
  • All other sources of pain have been excluded; and
  • All major psychosocial and substance abuse issues have been addressed.

*Clinically meaningful improvement: Global assessment showing at least 50% improvement.

 

Repeat lumbar decompression may be considered medically necessary when the following criteria are met:

  • Criteria above for initial primary lumbar decompression has been met; and
  • Recent (within 3 months) post-operative MRI with gadolinium/CT myelogram confirms radiographic evidence of neural structure compression; and
  • Greater than 12 weeks since last decompression surgery; and
  • Initial relief of symptoms following previous decompression procedure at same level(s).

 

Acceptable imaging modalities are CT scan, MRI and myelogram.

Imaging must be performed and read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, interpretations by the radiologist will supersede. Discography results will not be used as a determining factor of medical necessity for any requested procedures. Use is not endorsed.

 

The following procedures are considered investigational/experimental and therefore non-covered due to lack of supporting published peer reviewed literature:

  • Percutaneous Lumbar Discectomy
  • Percutaneous Laser Discectomy
  • Laser-assisted Disc Decompression
  • Percutaneous Laser Disc Decompression
  • Percutaneous nucleotomy

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 63017

 




Place of Service: Inpatient/Outpatient



The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.