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Section: |
Surgery |
Number: |
S-159 |
Topic: |
Nucleoplasty |
Effective Date: |
August 1, 2005 |
Issued Date: |
August 1, 2005 |
Date Last Reviewed: |
06/2005 |
General Policy Guidelines
Indications and Limitations of Coverage
Nucleoplasty is considered experimental/investigational, as there are no long term studies to support or prove the safety and efficacy of this procedure. Nucleoplasty is not covered and not eligible for reimbursement or payment. A participating, preferred, or network provider can bill the member for this service.
- NOTE:
- See Medical Policy Bulletin S-83 for guidelines on Percutaneous Lumbar Discectomy (PLD).
Description
Nucleoplasty (S2348) is a minimally invasive percutaneous procedure performed under local anesthesia to decompress herniated vertebral discs for the relief of chronic back pain. A special radiofrequency probe (Perc-D Spine Wand) is inserted percutaneously into the nucleus pulposis under fluoroscopic guidance. Radiofrequency energy is used to break up the molecular bonds of the gel in the nucleus of the disc, essentially vaporizing a portion of it. Upon withdrawal of the wand, tissue is thermally coagulated. The intent of the procedure is to decompress the disc thereby reducing the pressure on surrounding nerve roots. |
- NOTE:
- 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 circumstances may warrant individual consideration, based on review of applicable medical records.
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Procedure Codes
Traditional Guidelines
FEP Guidelines
Under the Federal Employees Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient's condition. Nucleoplasty is considered an eligible service when determined medically necessary based on the patient's condition.
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PPO Guidelines
Managed Care POS Guidelines
Publications
PRN References
12/2002, Nucleoplasty considered investigational
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References
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Glossary
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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 circumstances may warrant individual consideration, based on review of applicable medical records.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
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