Nucleoplasty
Nucleoplasty (S2348) 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.

Biacuplasty
Biacuplasty (64999) is considered experimental/investigational as published data are inadequate to permit scientific conclusions regarding the safety and efficacy of this procedure.  Biacuplasty is not covered and not eligible for 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).

NOTE:

See Medical Policy Bulletin S-169 for guidelines on Intradiscal Electrothermal Annuloplasty (IDEA) or Intradiscal Electrothermal Therapy (IDET).

Description

Nucleoplasty is a minimally invasive percutaneous procedure that was developed as an alternative to open discectomy for treatment of chronic back pain related to disc herniation.  Nucleoplasty may also be referred to as decompression nucleoplasty or plasma disc decompression.  Nucleoplasty is 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 of the affected disc under fluoroscopic guidance. Bipolar radiofrequency energy or cold energy plasma (coblation) is used to break up the molecular bonds of the gel in the nucleus of the disc, essentially vaporizing a portion of it and creating a channel.  A series of six separate channels are typically created, depending on the desired amount of tissue reduction within the affected disc. 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.

Biacuplasty is a minimally invasive percutaneous procedure performed under local anesthesia for the treatment of chronic discogenic pain originating from annular fissures or contained disc herniations.  The biacuplasty procedure uses a bipolar approach in conjunction with internally water-cooled radiofrequency probes to coagulate and deactivate nerves while decompressing disc material.  Under fluoroscopy, two introducers are placed bilaterally in the posterolateral disc and the radiofrequency (TransDiscal™) probes are inserted into the introducers.  The radiofrequency energy is applied and directed through the disc between the two probe electrodes.  This concentrated energy results in tissue heating around and between the electrodes, which coagulates and decompresses disc material, reducing pressure on nearby nerves..

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.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contact. Benefits are determined by the Federal Employee Program.

Percutaneous Disc Decompression in the Management of Chronic Low Back Pain, Orthopedic Clinics of North America, Vol. 35(1), January 2004

Nucleoplasty With or Without Intradiscal Electrothermal Therapy (IDET) as a Treatment for Lumbar Herniated Disc, Journal of Spinal Disorders & Techniques, 18 Supplement, February 2005

Side Effects and Complications After Percutaneous Disc Decompression Using Coblation Technology, American Journal of Physical Medicine and Rehabilitation, Vol 85(1), January 2006

Quality of Life Assessment in Patients Undergoing Nucleoplasty-Based Percutaneous Discectomy, Journal of Neurosurgery. Spine, Vol. 4(1), January 2006

National Blue Cross Blue Shield Association Medical Policy 7.01.93, Decompression of the Intervertebral Disc Using Laser (Laser Discectomy) or Radiofrequency (DISC Nucleoplasty™) Energy, March 2006

A Novel Radiofrequency Annuloplasty (Transdiscal Biacuplasty) for the Treatment of Lumbar Discogenic Pain: 6-Month Results of the Pilot Study, American Academy of Pain Medicine, February, 2007

The Results of Nucleoplasty in Patients with Herniated Disc: A Prospective Clinical Study of 52 Consecutive Patients, Spine, Vol 7 (1), January-February 2007

Outcomes of Percutaneous Disc Decompression Utilizing Nucleoplasty for the Treatment of Chronic Discogenic Pain, Pain Physician, Vol 10 (2), March 2007

Novel Intradiscal Biacuplasty (IDB) for the Treatment of Lumbar Discogenic Pain, Pain Practice: the Official Journal of World Institute of Pain, Vol. 2(2), June 2007

Nucleoplasty in the Treatment of Lumbar Discogenic Back Pain: One Year Follow-Up, Cardiovascular Interventional Radiology, Vol 30 (3), May-June 2007

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Calisaneller T. Six months post-operative clinical and 24 hour post-operative MRI examinations after nucleoplasty with radiofrequency energy. Acta Neurochir. 2007;149(5):495-500.

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Al-Zain F, Lemcke J, Killeen T, et al. Minimally invasive spinal surgery using nucleoplasty: a 1-year follow-up study. Acta Neurochir (Wien). 2008;150(12):1257-62.

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Kapural L, Ng A, Dalton J, Mascha E, Kaprual M, Garza M, Makhail N. Intervertebral Disc Biacuplasty for the Treatment of Lumbar Discogenic Pain: Results of a Six-Month Follow-Up. Pain Medicine. 2008;9(1):60-67.

Kapural L. Intervertebral disk cooled bipolar radiofrequency (intradiskal biacuplasty) for the treatment of lumbar diskogenic pain: a 12-month follow-up of the pilot study. Pain Medicine. 2008;9(4):407-8.

Li J, Yan DL, Zhang ZH. Percutaneous cervical nucleoplasty in the treatment of cervical disc herniation. Eur Spine J. 2008;17(12): 1664-9.

Birnbaum K. Percutaneous cervical disc decompression. Surg Radiol Anat. 2009; 31(5): 379-87.

Chou R, Atlas SH, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine. 2009; 34(10):1078-93.

Helm S, Hayek SM, Benyamin RM, Manchikanti L. Systematic review of the effectiveness of thermal annular procedures in treating discogenic low back pain. Pain Physician. 2009;12(1):207-32.

Kapural L, Cata JP, Narouze S. Successful treatment of lumbar discogenic pain using intradiscal biacuplasty in previously discectomized disc. Pain Practice. 2009;9(2):130-4.

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Manchikanti L, Derby R, Benyamin RM, et al. A systemic review of mechanical lumbar disc decompression with nucleoplasty. Pain Physician. 2009;12(3):561-72.

Gerges FJ, Lipsitz SR, Nedeljkovic SS. A systematic review on the effectiveness of the nucleoplasty procedure for discogenic pain. Pain Physician. 2010 Mar-Apr;13(2):117-32.

Bokov A, Skorodumov A, Isrelov A, et al. Differential treatment of nerve root compression pain caused by lumbar disc herniation applying nucleoplasty. Pain Physician. 2010 Sep-Oct;13(5):469-480.

Karaman H, Tüfek A, Kavak GÖ, Kaya S, Yildirim ZB, Uysal E, Çelik F. 6-Month Results of Transdiscal Biacuplasty on Patients with Discogenic Low Back Pain: Preliminary Findings. Int J Med Sci. 2011; 8:1-8.

Zhu H, Zhou XZ, Cheng MH, et al. The efficacy of coblation nucleoplasty for protrusion of lumbar intervertebral disc at a two-year follow-up. Int Orthop. 2011 Nov;35(11):1677-82.