L29316-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Surgical Decompression for

Peripheral Polyneuropathy (L29316)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29316

LCD Title Surgical Decompression for Peripheral Polyneuropathy

Contractor's Determination Number 64702

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 01/01/2011

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determination (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 administrative

law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represent quotation from one or more of the following CMS sources:

N/A

Indications and Limitations of Coverage and/or Medical Necessity

Peripheral polyneuropathy leads to damage of the nerves in the arms and legs, with the feet and legs usually affected before the hands and arms. Symptoms of peripheral neuropathy, which are often worse at night, may include numbness or insensitivity to pain or temperature, tingling, burning, or prickling sensations, sharp pains or cramps, extreme sensitivity to touch and loss of balance coordination.

At present, the preponderance of clinical evidence as noted in various publications in the peer-reviewed literature is not sufficient to support the efficacy of surgical decompression of peripheral nerves for the treatment of symptomatic diabetic metabolic, inflammatory or toxic polyneuropathy. Therefore, this Local Coverage Determination (LCD) finds surgical decompression of peripheral nerves as not reasonable and necessary and therefore not eligible for reimbursement by Medicare.

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

01470 ANESTHESIA FOR PROCEDURES ON NERVES, MUSCLES, TENDONS, AND FASCIA OF LOWER LEG, ANKLE, AND FOOT; NOT OTHERWISE SPECIFIED

28035 RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION)

64702 NEUROPLASTY; DIGITAL, 1 OR BOTH, SAME DIGIT

64704 NEUROPLASTY; NERVE OF HAND OR FOOT

64708 NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED

64712 NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; SCIATIC NERVE

64714 NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; LUMBAR PLEXUS

64722 DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY)

64726 DECOMPRESSION; PLANTAR DIGITAL NERVE

64727 INTERNAL NEUROLYSIS, REQUIRING USE OF OPERATING MICROSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR NEUROPLASTY) (NEUROPLASTY INCLUDES EXTERNAL NEUROLYSIS)

ICD-9 Codes that Support Medical Necessity XX000 Not Applicable

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity

For CPT codes 28035, 64702, 64704, 64708, 64712, 64714, 64722, 64726 and 64727

250.60 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.61

DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED

250.62 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED

356.4 IDIOPATHIC PROGRESSIVE POLYNEUROPATHY

356.8 OTHER SPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY

357.1 POLYNEUROPATHY IN COLLAGEN VASCULAR DISEASE

357.2 POLYNEUROPATHY IN DIABETES

357.3 POLYNEUROPATHY IN MALIGNANT DISEASE

357.4 POLYNEUROPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE

357.5 ALCOHOLIC POLYNEUROPATHY

357.6 POLYNEUROPATHY DUE TO DRUGS

357.7 POLYNEUROPATHY DUE TO OTHER TOXIC AGENTS

357.81 CHRONIC INFLAMMATORY DEMYELINATING POLYNEURITIS

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

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements N/A

Appendices

Utilization Guidelines N/A

Sources of Information and Basis for Decision

Chaudhry V, Stevens J, Kincaid J, So Y..(2006) Practice advisory: utility of surgical decompression for treatment of diabetic neuropathy: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2006; 66: 1805-1808.

Investigations in Patients with Neuropathy Noble: Textbook of Primary Care Medicine, 3rd ed. 2001 Mosby, Inc. retrieved From MD Consult

Kale B, Yϋksel F, Bahattin Ç,et al. Effect of various nerve decompression procedures on the functions of distal limbs in streptozotocin-induced diabetic rats further optimism in diabetic neuropathy. Plastic and Reconstructive Surgery 2003;111(7):2265-2272.

Lee CH, Dellon AL. Prognostic ability of tinel sign in determining outcome for decompression surgery in diabetic and non diabetic neuropathy. Ann Plast Surg 2004;53: 523-527.

Scientific Basis for Nerve Compression in Diabetic Neuropathy retrieved from internet February 19, 2007.

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.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 01/01/2011

Revision History Number 1

Revision History Explanation Revision Number1 Start Date of Comment Period:N/A

Start Date of Notice Period:01/01/2011 Revision Effective Date 01/01/2011

LCR B2011-008

December 2010 Update

Explanation of Revision: Annual 2011 HCPCS Update. Descriptors revised for CPT codes 64708, 64712 and 64714. 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-

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 (L29316) replaces LCD L25283 as the policy in notice. This document (L29316) is effective on 02/02/2009.

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

01470 descriptor was changed in Group 1 64708 descriptor was changed in Group 1 64712 descriptor was changed in Group 1 64714 descriptor was changed in Group 1

Reason for Change