Dynamic spine stabilization for the treatment of degenerative spine disorders is considered experimental/investigational and therefore, non-covered as there is a lack of conclusive evidence indicating a positive impact to overall health outcomes. A participating, preferred, or network provider can bill the member for the non-covered service.

Description

Dynamic stabilization systems (e.g., the Dynesys Spinal System) are intended to restrict segmental motion and thus prevent further degeneration of the lumbar spine. The Dynesys, a non-fusion pedicle screw stabilization system (a flexible posterior stabilization system), was developed in an attempt to overcome the inherent disadvantages of rigid instrumentation and fusion. It uses flexible materials threaded through pedicle screws rather than rigid rods or bone grafts alone as an adjunct to fusion. The Dynesys is installed posteriorly, and does not require bone to be taken from the hip, as is required in other fusion procedures. It is designed to prevent over-loading the disc, but it restricts extension and reduces lordosis.

Dynamic stabilization devices use flexible material to stabilize the spine and alter load transmission without the purpose of fusing the segment. It leaves the spinal segment mobile and may be referred to as soft stabilization, semi-rigid stabilization, or flexible stabilization. In theory, the device controls abnormal motion and more physiologic load transmission to ease pain and prevent adjacent segment deterioration. Once this is achieved, the damaged disc may repair itself.

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 contract. Benefits are determined by the Federal Employee Program.

Schwarzenbach O, Berlemann U. Dynamic posterior stabilization with the pedicle screw system DYNESYS®. Oper Orthop Traumatol. 2010;22(5-6):545-557.

Lee MJ, Lindsey JD, Bransford RJ. Pedicle screw-based posterior dynamic stabilization in the lumbar spine. J Am Acad Orthop Surg. 2010;18(10):581-588.

Di Silvestre M., Lolli F, Bakaloudis G, Parisini P. Dynamic stabilization for degenerative lumbar scoliosis in elderly patients. Spine. 2010;35(2):227-234.

Li ZH, Wang SY, Tang H, et al. Spinal fusion combined with dynamic interspinous fixation with Coflex system for lumbar degenerative disease. Zhongguo Gu Shang. 2011;24(4):277-281.

Klöckner C, Beck A. Polysegmental Dynesys system. Orthopade. 2011;40(2):156-161.

Kim CH, Chung CK, Jahng TA. Comparisons of outcomes after single or multilevel dynamic stabilization: Effects on adjacent segment. J Spinal Disord Tech. 2011;24(1):60-67.

Galbusera F, Bellini CM, Anasetti F, et al. Rigid and flexible spinal stabilization devices: a biomechanical comparison. Med Eng Phys. 2011;33(4):490-496.