Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-83
Topic: Percutaneous Lumbar Discectomy
Effective Date: January 15, 2007
Issued Date: September 10, 2007
Date Last Reviewed: 06/2006

General Policy Guidelines

Indications and Limitations of Coverage

Percutaneous lumbar discectomy (PLD) is considered experimental/investigational. The published data regarding PLD for treatment of herniated intervertebral discs are inadequate to permit scientific conclusions.  Percutaneous lumbar discectomy is not covered and is not eligible for payment.  A participating, preferred, or network provider can bill the member for this service.

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 or microdiscectomy for treatment of back pain related to disc hernation.

The probe used to perform this procedure is placed into the herniated disc through a small cannula under fluoroscopic guidance. 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.  Removal/ablation of lumbar disc material causes decompression of the disc, relieving painful pressure on surrounding 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.

Procedure Codes

62287     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

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.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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

Discectomy Strategies for Lumbar Disc Herniation: Study Design and Implications for Clinical Research, Journal of Clinical Neuroscience, Vol. 9 (4), 7/2002

Percutaneous Nucleotomy: Preliminary Communication on a Decompression Probe in Percutaneous Discectomy, Journal of Clinical Imaging, Vol. 29, 2005

View Previous Versions

[Version 002 of S-83]
[Version 001 of S-83]

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.