Percutaneous lumbar discectomy (PLD) is a covered procedure in patients who have physical and diagnostic imaging evidence of an uncomplicated herniated disc and no evidence of a free fragment or sequestered disc and meet all of the following criteria:

• Major complaint of acute unilateral leg pain localized to a single dermatome or a major complaint of acute back and leg pain consistent with a single herniation contained within the annulus of the disc.
  
  
• Neurologic signs or symptoms that are consistent with a single herniation contained within the annulus of the disc (e.g., sensory abnormalities, reflex alterations, positive straight leg-raising test, weakness).
  
  
• Magnetic resonance imaging, CT, or myelographic evidence of a herniation that is contained within the annulus of the lumbar disc (L1-2 through L5-S1) and is consistent with the signs and symptoms.
  
  
• Failure of a well-managed course of conservative treatment to relieve pain and other signs and symptoms.

In cases where these criteria are not met, percutaneous lumbar discectomy is considered an experimental/investigational procedure and is not eligible. Scientific evidence does not demonstrate the efficacy of percutaneous lumbar discectomy without the above criteria elements having been met.

NOTE:

See Medical Policy Bulletin S-159 for guidelines on Nucleoplasty.

Description

Percutaneous lumbar discectomy (62287) is a surgical technique used for the removal of herniated lumbar disc material. This procedure can be used as an alternative to the standard open discectomy.

The probe used to perform this procedure is placed into the herniated disc through a small cannula under fluoroscopic control. Once positioned, the probe will resect and aspirate the herniated disc material, or a laser may be used to ablate the herniated portion of the disc.

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.

Under the Federal Employee's 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. Percutaneous lumbar discectomy is considered an eligible service when determined medically necessary based on the patient's condition.

PRN References

05/1994, Percutaneous lumbar discectomy (PLD), reimbursement for

Percutaneous Lumbar Discectomy, Medical Policy Reference Manual, Policy 7.01.18, 12/1/95

Percutaneous Lumbar Discectomy, Consortium Health Plans, Inc., Policy 7.01.18, 12/1/95

Nuances in Percutaneous Discectomy, Radiologic Clinics of North America, Vol. 36, No. 3, 5/98

Laminectomy Compared with Laparoscopic Diskectomy and Outpatient Laparoscopic Diskectomy for Herniated L5-S1 Intervertebral Disks, Journal of Laparoendoscopic and Advanced Surgical Techniques, Vol. 8, No. 5, 10/98