Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-169
Topic: Intradiscal Electrothermal Annuloplasty (IDEA) or Intradiscal Electrothermal Therapy (IDET)
Effective Date: August 1, 2005
Issued Date: August 7, 2006
Date Last Reviewed: 06/2006

General Policy Guidelines

Indications and Limitations of Coverage

Intradiscal electrothermal annuloplasty (IDEA), or intradiscal electrothermal therapy (IDET), (0062T, 0063T), is considered experimental/investigational, as there is insufficient evidence in medical literature regarding the efficacy, mechanism of action, and long-term effects of the procedure.  IDEA/IDET is not covered and not eligible for reimbursement or payment.  A participating, preferred, or network provider can bill the member for this service.

Description

Intradiscal electrothermal annuloplasty (IDEA), or intradiscal electrothermal therapy (IDET) is a minimally invasive outpatient procedure used in the treatment of chronic low back pain related to degenerative disc disease.  It was developed to offer patients with chronic discogenic low back pain an option other than chronic pain management or non-operative treatments such as non-steroidal anti-inflammatory medication, epidural and intradiscal steroid injections, exercise, and manual therapies. 

IDEA/IDET involves the use of a disposable intradiscal catheter and an electrothermal generator to deliver a controlled level of heat to contained herniated intervertebral discs.  The catheter is directed circuitously within the disc until the heating element is appropriately positioned for treatment.  When the catheter is properly positioned, electrothermal heat is generated.  Although the specific mechanism of action involved with IDEA/IDET is unknown, the heat it generates is sufficient to contract and thicken collagen in the disc wall, causing closure or contraction of fissures, and reduced disc herniations and protrusions.  In addition, during the procedure, the disc wall reaches temperatures at which nerve endings have been known to coagulate.  It is believed that the destruction of pain-sensing nerve endings (nociceptors) in the disc wall may contribute to pain relief.


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.

Procedure Codes

0062T0063T    

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Under the Federal Employee 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. Intradiscal electrothermal annuloplasty/therapy (IDEA/IDET) is considered an eligible service when determined medically necessary based on the patient’s condition.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

10/2004, Reporting of intradiscal electrothermal annuloplasty (IDEA) or intradiscal electrothermal therapy (IDET) has changed

References

Intradiscal Electrothermal Treatment for Chronic Discogenic Low Back Pain, Spine, Vol. 25, 2000

 Cauda Equina Syndrome From Intradiscal Electrothermal Therapy, Neurology, Vol. 25, 2000

Twelve Month Follow-Up of a Controlled Trial of Intradiscal Thermal Annuloplasty for Back Pain Due to Internal Disc Disruption, Spine, Vol. 25, 2000

Effectiveness of Intradiscal Electrothermal Therapy in Increasing Function and Reducing Chronic Low Back Pain in Selected Patients, Wisconsin Medical Journal, Vol. 101, 2002

Intradiscal Electrothermal Treatment for Chronic Discogenic Low Back Pain, Spine, Vol. 27, 2002

Treatment of Chronic Lumbar Diskogenic Pain With Intradiscal Electrothermal Therapy: A Prospective Outcome Study, Archives of Physical Medicine and Rehabilitation, Vol. 84, January 2003

Percutaneous Intradiscal Electrothermal Annuloplasty and Percutaneous Intradiscal Radiofrequency Thermocoagulation, Medical Policy Reference Manual, Policy 7.01.72, 12/17/03

A Randomized, Placebo-Controlled Trial of Intradiscal Electrothermal Therapy for the Treatment of Discogenic Low Back Pain, The Spine Journal, Vol. 4, 2004

View Previous Versions

[Version 001 of S-169]

Table Attachment

Text Attachment

Procedure Code Attachment


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.