Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-162
Topic: Laminoplasty
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 07/2005

General Policy Guidelines

Indications and Limitations of Coverage

Laminoplasty, or open-door laminoplasty, (63050, 63051) is a procedure that is performed to relieve severe cervical spinal cord compression.  Laminoplasty is similar to laminectomy, except that the lamina is not removed, but is carefully split apart or hinged on one side and rotated away from the spinal cord.  This procedure allows marked expansion of the diameter of the spinal canal and relieves compression of the spinal cord.  Laminoplasty may be considered an alternative to laminectomy.

Laminoplasty is eligible for payment in patients with symptomatic multiple level (3 or more) cervical spondylosis (narrowing of the spinal canal [721.1]).  Symptoms may include pain, compressive myelopathy (weakness in the arms and/or legs [728.9]), and/or unsteadiness in the gait (781.2).

Procedure Codes

6305063051    

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

Treatment of Degenerative Cervical Disc Disease, Neurologic Clinics,
02/2001

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Glossary




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.