L29256-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Endoscopic and Percutaneous Lysis of Epidural Adhesions (L29256)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29256

LCD Title Endoscopic and Percutaneous Lysis of Epidural Adhesions

Contractor's Determination Number 62263

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2010

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administratice law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: N/A

Indications and Limitations of Coverage and/or Medical Necessity

Endoscopic epidural lysis of adhesions (also known as endoscopic lysis) and percutaneous epidural lysis of adhesions (also referred to as epidural neuroplasty or epidural adhesiolysis) are interventional pain management techniques that are used to treat chronic cervical, lumbar, and thoracic pain. The basis for performing this procedure is the premise that fibrous adhesions (scar tissue) develops after surgery, trauma, and/or inflammation that compounds pain associated with the nerve root by fixing it in one position and thus increasing the susceptibility of the nerve root to tension or compression. This scar tissue also prevents the direct application of medications to relieve pain (local anesthetics and corticosteroids) to the problem area. The goal of the procedure is to break down these fibrous adhesions to allow for delivery of high concentrations of injected drugs to the target area and free the nerve from mechanical tension/compression. The procedure usually involves adhesiolysis procedures performed over a 1-3 day period (CPT code 62263 – more than 2 days or 62264 – one day). Adhesiolysis can be accomplished by solution injection (commonly hypertonic saline and/or hyaluronidase) and/or by mechanical means (by maneuvering a specially designed epidural catheter or epiduroscope).

Medicare will consider the use of endoscopic and percutaneous lysis of epidural adhesions to be medically reasonable and necessary in the treatment of chronic refractory cervical, lumbar, and thoracic pain that has failed to respond to more conservative treatment measures. Conservative treatment may include local heat, traction, nonsteroidal anti-inflammatory medications, and anesthetic and/or steroid epidural injections. The chronic refractory low back pain may be secondary to post lumbar laminectomy syndrome, intervertebral lumbar disc disruption, lumbar epidural adhesions, and/or lumbar degenerative disc disorder. It is not expected that services will exceed one every six months to the same anatomical region. Services exceeding one every six months may be subject to medical review.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

64999 Unlisted procedure, nervous system (Endoscopic lysis of epidural adhesions with the epiduroscope) PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING SOLUTION INJECTION (EG, HYPERTONIC

62263 SALINE, ENZYME) OR MECHANICAL MEANS (EG, CATHETER) INCLUDING RADIOLOGIC LOCALIZATION

(INCLUDES CONTRAST WHEN ADMINISTERED), MULTIPLE ADHESIOLYSIS SESSIONS; 2 OR MORE DAYS

PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING SOLUTION INJECTION (EG, HYPERTONIC 62264 SALINE, ENZYME) OR MECHANICAL MEANS (EG, CATHETER) INCLUDING RADIOLOGIC LOCALIZATION

(INCLUDES CONTRAST WHEN ADMINISTERED), MULTIPLE ADHESIOLYSIS SESSIONS; 1 DAY

64999 UNLISTED PROCEDURE, NERVOUS SYSTEM

ICD-9 Codes that Support Medical Necessity

722.0 DISPLACEMENT OF CERVICAL INTERVERTEBRAL DISC WITHOUT MYELOPATHY

722.10 DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY

722.4 DEGENERATION OF CERVICAL INTERVERTEBRAL DISC

722.52 DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC

722.73 INTERVERTEBRAL DISC DISORDER WITH MYELOPATHY LUMBAR REGION

722.81 POSTLAMINECTOMY SYNDROME OF CERVICAL REGION

722.82 POSTLAMINECTOMY SYNDROME OF THORACIC REGION

722.83 POSTLAMINECTOMY SYNDROME OF LUMBAR REGION

723.0 SPINAL STENOSIS IN CERVICAL REGION

723.4 BRACHIAL NEURITIS OR RADICULITIS NOS

724.1 SPINAL STENOSIS OF THORACIC REGION

724.2 SPINAL STENOSIS, LUMBAR REGION, WITHOUT NEUROGENIC CLAUDICATION

724.3 SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION

724.4 THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation maintained by the performing physician must clearly indicate the medical necessity of the service being billed. In addition, documentation that the service was performed must be included in the patient’s medical record. This information is normally found in the office/progress notes, hospital notes, and/or procedure report.

In addition, the medical record should clearly document the nature of the cervical, lumbar, or thoracic pain. This should include the location, intensity, type of pain present, and contributing factors (if any), duration of condition, and treatment regimes that have been utilized. Documentation should demonstrate failure of more conservative management in the treatment of the patient’s condition. This more conservative treatment may include local

heat, traction, nonsteroidal anti-inflammatory medications, and anesthetic and/or steroid epidural injections.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they

may be subject to review for medical necessity.

Sources of Information and Basis for Decision

Boswell, M. V., Trescot, A. M., et al Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 10:7 pp 48-51.

Manchikanti, l., Heavner, J., Boswell, M.V. (2007) Endoscopic lumbar epidural adhesions. Intervential Techniques in Chronic Spinal Pain. Pp 507-526

Manchikanti, L., Boswell, M.V., et al. A randomized controlled trial of spinal endoscopic adhesiolysis in chronic refractory low back and lower extremity pain. BMC Anesthesiology 2005 (5) 10

Manchikanti, L., Singh, V (2007) Pecutaneous lysis of lumbar epidural adhesions. Interventional Techniques in Chronic Spinal Pain. Pp479-506

Racz, G.B., Heavner, J.E., Trescot, A. (2008) Percutaneous lysis of epidural adhesions-evidence for safety and efficacy. Pain Practice 8 (4) 277-286.

Trescot A.M., Chopra P., Abdi S., Datta S., Schultz D.M. Systematic review of effectiveness and complications of adhesiolysis in the management of chronic spinal pain: An update. Pain Physician 2007; 10: 129-146. http://www.painphysicianjournal.com/2007/january/2007;10;129-146.pdf

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from numerous societies.

Florida Contractor Advisory Committee Meeting held on June 20, 2009.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 10/01/2010

Revision History Number 2

Revision History Explanation Revision Number: 2 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2010 Revised Effective Date: 10/01/2010

LCR B2010-071

September 2010 Update

Explanation of Revision: Annual 2011 ICD-9-CM Update. Added ICD-9-CM code 724.03. Revised descriptor for ICD-9-CM code 724.02. The effective date of this revision is based on date of service.

Revision Number:1

Start Date of Comment Period:06/01/2009 Start Date of Notice Period:08/15/2009 Revised Effective Date: 09/30/2009

LCR B2009-087

August 2009 Update

Explanation of Revision: LCD revised to include endoscopic lysis of epidural adhesions. Title of LCD changed to include “Endoscopic” lysis of epidural adhesions. Updated “Sources of Information and Basis for Decision ” section. Updated “CPT/HCPCS code” section to include 64999 [Unlisted procedure, nervous system] to be reported when billing for endoscopic lysis of epidural adhesions. Updated the “ICD-9 Codes that Support Medical Necessity” section to include ICD-9-CM codes 722.0, 722.4, 722.81, 722.82, 723.0, 723.4, 724.01 and 724.02. Coding Guidelines were developed. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-044FL

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29256) replaces LCD L6164 as the policy in notice. This document (L29256) is effective on 02/02/2009.

09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.

Reason for Change