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Automated Percutaneous and Percutaneous Endoscopic Discectomy

Policy Number: MP-137

Latest Review Date: July 2023

Category:  Surgery                                                                 

 

POLICY:

Automated percutaneous discectomy is considered investigational as a technique of intervertebral disc decompression in patients with back pain and/or radiculopathy related to disc herniation in the lumbar, thoracic or cervical spine.

Percutaneous endoscopic discectomy is considered investigational as a technique of intervertebral disc decompression in patients with back pain and/or radiculopathy related to disc herniation in the lumbar, thoracic or cervical spine.

DESCRIPTION OF PROCEDURE OR SERVICE:

Surgical management of herniated intervertebral discs most commonly involves discectomy or microdiscectomy, performed manually through an open incision. Automated percutaneous discectomy involves placement of a probe within the intervertebral disc under image guidance with aspiration of disc material using a suction cutting device. Removal of disc herniations under endoscopic visualization is also being investigated. Endoscopic discectomy involves the percutaneous placement of a working channel under image guidance, followed by visualization of the working space and instruments through an endoscope, and aspiration of disc material.

Back pain or radiculopathy related to herniated discs is an extremely common condition and a frequent cause of chronic disability. Although many cases of acute low back pain and radiculopathy will resolve with conservative care, surgical decompression is often considered when the pain is unimproved after several months and is clearly neuropathic in origin, resulting from irritation of the nerve roots. Open surgical treatment typically consists of discectomy in which the extruding disc material is excised. When performed with an operating microscope, the procedure is known as microdiscectomy.

Minimally invasive options have also been researched, in which some portion of the disc material is removed or ablated, although these techniques are not precisely targeted at the offending extruding disc material. Ablative techniques include laser discectomy and radiofrequency (RF) decompression. In addition, intradiscal electrothermal annuloplasty (also known as intradiscal electrothermal therapy [IDET]) is another minimally invasive approach to low back pain. In this technique, RF energy is used to treat the surrounding disc annulus. (See Medical Policy #090: Decompression of the Intervertebral Disc Using Laser Energy [Laser Discectomy] or Radiofrequency Coblation [Nucleoplasty] and Medical Policy #041: Percutaneous Intradiscal Electrothermal Annuloplasty (IDET), Radiofrequency Annuloplasty and Biacuplasty).

This policy addresses automated percutaneous and endoscopic discectomy, in which the disc decompression is accomplished by the physical removal of disc material rather than its ablation. Traditionally, discectomy is performed manually through an open incision, using cutting forceps to remove nuclear material from within the disc annulus. This technique has been modified by automated devices that involve placement of a probe within the intervertebral disc and aspiration of disc material using a suction cutting device. Endoscopic techniques may be intradiscal or may involve the extraction of non-contained and sequestered disc fragments from inside the spinal canal using an interlaminar or transforaminal approach. Following insertion of the endoscope, the decompression is performed under visual control.

KEY POINTS:

The most recent literature search was performed through May 5, 2023. Following is a summary of the key literature to date.

Summary of Evidence

For individuals who have herniated intervertebral disc(s) who receive automated percutaneous discectomy, the evidence includes randomized controlled trials (RCTs) and systematic reviews of RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment related morbidity. The published evidence is insufficient to evaluate the impact of automated percutaneous discectomy on the net health outcome. Evidence from small RCTs does not support the use of this procedure. Well-designed and executed RCTs are needed to determine the benefits and risks of this procedure. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have herniated intervertebral disc(s) who receive endoscopic percutaneous discectomy, the evidence includes a number of RCTs and systematic reviews of RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment related morbidity. Many of the more recent RCTs are conducted at institutions within China. There are few reports from the United States. Results do not reveal a consistently significant improvement in patient-reported outcomes and treatment-related morbidity with percutaneous endoscopic discectomy in comparison to other discectomy interventions. The evidence is insufficient to determine the effects of the technology on health outcomes.

 

Practice Guidelines and Position Statements

National Institute for Health and Care Excellence

The National Institute for Health and Clinical Excellence (NICE) published guidance in 2005 on automated percutaneous mechanical lumber discectomy, indicating that there is limited evidence of efficacy based on uncontrolled case series of heterogeneous groups of patients, and evidence from small randomized controlled trials shows conflicting results. The guidance states that in view of uncertainty about the efficacy of the procedure, it should not be done without special arrangements for consent and for audit or research. The guidance was considered for review in 2009, but did not meet the review criteria; the 2005 guidance is therefore considered current.

A NICE guideline on percutaneous transforaminal endoscopic lumbar discectomy for sciatica was published in 2016.  The guidance has stated that current evidence is adequate to support the use of percutaneous transforaminal endoscopic lumbar discectomy for sciatica. Choice of operative procedure (open discectomy, microdiscectomy, or percutaneous endoscopic approaches) may be influenced by symptoms, and location and size of prolapsed disc.

A NICE guidance on percutaneous interlaminar endoscopic lumbar discectomy for sciatica was published in 2016. The guidance stated that current evidence is adequate to support the use of percutaneous interlaminar endoscopic lumbar discectomy for sciatica. Choice of operative procedure (open discectomy, microdiscectomy, or percutaneous endoscopic approaches) may be influenced by symptoms, and location and size of prolapsed disc.

American Society of Interventional Pain Physicians

The 2013 guideline update from the American Society of Interventional Pain Physicians states that the evidence for percutaneous disc decompression with Dekompressor is limited. There were no recommended indications for Dekompressor.

North American Spine Society

In 2014, the North American Spine Society published clinical guidelines on the diagnosis and treatment of lumbar disc herniation.  Table 1 summarizes recommendations specific to endoscopic percutaneous discectomy and automated percutaneous discectomy.

 

Table 1. NASS Recommendations for Lumbar Disc Herniation with Radiculopathy

Recommendations

Grade or LOEa

Endoscopic percutaneous discectomy is suggested for carefully selected patients to reduce early postoperative disability and reduce opioid use compared with open discectomy.

B

There is insufficient evidence to make a recommendation for or against the use of automated percutaneous discectomy compared with open discectomy.

I

Endoscopic percutaneous discectomy may be considered for treatment.

C

Automated percutaneous discectomy may be considered for treatment.

C

Patients undergoing percutaneous endoscopic discectomy experience better outcomes if <40 years and symptom duration <3 months.

II

LOE: level of evidence; NASS: North American Spine Society

a Grade B: fair evidence (level II or III studies with consistent findings; grade C: poor quality evidence (level IV or V studies).

b Level of evidence II: lesser quality randomized controlled trial (e.g., <80% follow-up, no blinding, or improper randomization), prospective comparative study, systematic review of level II studies or level I studies with inconsistent results; level of evidence III: case control, retrospective, systematic review of level III studies; level of evidence IV: case series; level of evidence V: expert opinion.

American Pain Society

The 2009 clinical practice guidelines from the American Pain Society found insufficient evidence to evaluate alternative surgical methods to standard open discectomy and microdiscectomy, including laser or endoscopic-assisted techniques, various percutaneous techniques, coblation nucleoplasty, or the Dekompressor.

 

American Society of Pain and Neuroscience

The American Society of Pain and Neuroscience (ASPN; 2022) published clinical guidance for interventional treatments for low back pain. The guideline states that discectomy procedures (such as percutaneous and endoscopic disc procedures) have favorable safety and efficacy profiles for the treatment of lumbar disc herniation with persistent radicular symptoms; however, it is stated that further research is needed to evaluate complications rates in order for these procedures to supplant classic open microdiscectomy. Recommendations specific to percutaneous endoscopic discectomy are summarized in the table below.

 

 

Table 2. Recommendations for Percutaneous and Endoscopic Procedures

Recommendation

Gradea

Level of Evidenceb

Level of Certainty [Net Benefit]c

Percutaneous Endoscopic Discectomy

B

I-a

High

 

a Grade B: (The ASPN Back Group recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

b Evidence Level: I-A: At least one controlled and randomized clinical trial, properly designed

U.S. Preventive Services Task Force Recommendations

Not Applicable.

KEY WORDS:

Percutaneous endoscopic discectomy, herniated disc, LDH, lumbar disc herniation, Yess procedure, Yeung procedure, Yeung endoscopic spinal surgery, SED, selective endoscopic discectomy, PLD, percutaneous lumbar discectomy, IDET, intradiscal electrothermal therapy, IEA, intradiscal electrothermal annuloplasty, MED, microendoscopic discectomy, percutaneous radiofrequency thermo-modulation, percutaneous intradiscal radiofrequency thermocoagulation, Nucleoplasty, microdiscectomy, laser-assisted discectomy, LADD, open microdiscectomy, METRx™, Dekompressor, Stryker, Laurimed

APPROVED BY GOVERNING BODIES:

The Stryker DeKompressor® Percutaneous Discectomy Probe (Stryker), Herniatome Percutaneous Discectomy Device (Gallini Medical Devices), and the Nucleotome® (Clarus Medical) are examples of percutaneous discectomy devices that received clearance from the U.S. Food and Drug Administration (FDA) through the 510(k) process. Both have the same labeled intended use, i.e., “for use in aspiration of disc material during percutaneous discectomies in the lumbar, thoracic and cervical regions of the spine.”

A variety of endoscopes and associated surgical instruments have received marketing clearance through the FDA’s 510(k) process.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP: Special benefit consideration may apply. Refer to member’s benefit plan.

CURRENT CODING:

CPT codes:

62287

Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar 

62380

Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar.

0274T

Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), single or multiple levels, unilateral or bilateral; cervical or thoracic

0275T

          ; lumbar                

 

HCPCS Codes:

C2614

Probe, percutaneous lumbar discectomy

             

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  87. Wang B, Lu G, Patel AA et al. An evaluation of the learning curve for a complex surgical technique: the full endoscopic interlaminar approach for lumbar disc herniations. Spine J 2011; 11(2):122-130.
  88. Wang H, Song Y, Cai L. Effect of percutaneous transforaminallumbar spine endoscopic discectomy on lumbar disc herniationand itsinfluence on indexes of oxidative stress. Biomed Res 2017;28.
  89. Wang M, Zhou Y, Wang J, et al. A 10-year follow-up study on long-term clinical outcomes of lumbar microendoscopic discectomy. J Neurol Surg A Cent Eur Neurosurg. Aug 2012; 73(4):195-198.
  90. Wu XC, Zhou Y, Li CQ. Percutaneous tranforaminal endoscopic discectomy versus microendoscopic discectomy for lumbardisc herniation: a prospective randomized controlled study. J Third Mil Med Univ. 2009;31(9):843-846.
  91. Wu YM, Bai M, Yin HP, et al. Comparison of the efficacies between two kinds of minimally invasive procedures for the treatment of simple lumbar disc herniation. J Pract Orthop. 2018;24(4):357-360.
  92. Xu J, Li Y, Wang B, et al. Minimum 2-Year Efficacy of Percutaneous Endoscopic Lumbar Discectomy versus Microendoscopic Discectomy: A Meta-Analysis. World Neurosurg. Feb 26 2020; 138: 19-26.
  93. Xu G, Zhang C, Zhu K, et al. Endoscopic removal of nucleus pulposus of intervertebral disc on lumbar intervertebral disc protrusion andthe influence on inflammatory factors and immune function. Exp Ther Med. Jan 2020; 19(1): 301-307.
  94. Yang L, Liao XQ, Zhao XJ, et al. Comparison of surgical outcomes between percutaneous transforaminal endoscopic discectomy and micro-endoscopic discectomy for lumbar disc herniation. China J Endosc. 2015;21(9):962-965.
  95. Yao Y, Zhang H, Wu J, et al. Minimally Invasive Transforaminal Lumbar Interbody Fusion Versus Percutaneous Endoscopic LumbarDiscectomy: Revision Surgery for Recurrent Herniation After Microendoscopic Discectomy. World Neurosurg. Mar 2017; 99: 89-95.
  96. Yao Y, Zhang H, Wu J, et al. Comparison of Three Minimally Invasive Spine Surgery Methods for Revision Surgery for RecurrentHerniation After Percutaneous Endoscopic Lumbar Discectomy. World Neurosurg. Apr 2017; 100: 641-647.e1.
  97. Yoon SM, Ahn SS, Kim KH, et al. Comparative Study of the Outcomes of Percutaneous Endoscopic Lumbar Discectomy and Microscopic Lumbar Discectomy Using the Tubular Retractor System Based on the VAS, ODI, and SF-36. Korean J Spine. Sep 2012; 9(3): 215-22.
  98. Yu, PP, Qiang, HH, Zhou, JJ, Huang, PP. Percutaneous Transforaminal Endoscopic Discectomy versus Micro-Endoscopic Discectomy for Lumbar Disc Herniation.. Med. Sci. Monit., 2019 Mar 31;25:2320-2328.
  99. Zhao XM, Chen AF, Lou XX, et al. Comparison of Three Common Intervertebral Disc Discectomies in the Treatment ofLumbar Disc Herniation: A Systematic Review and Meta-Analysis Based on Multiple Data. J Clin Med. Nov 08 2022;11(22).
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  101. Zhao W, Li CQ, Zhou Y, Wang J, Zheng WJ : Surgical treatment of the lumbar disc herniated discs using transforaminal endoscopicsurgerysystem. Orthop J China 20 : 1191-1195, 2012.
  102. Zhao XM, Yuan QL, Liu L, et al. Is It Possible to Replace Microendoscopic Discectomy with Percutaneous Transforaminal Discectomy for Treatment of Lumbar Disc Herniation? A Meta-Analysis Based on Recurrence and Revision Rate. J Korean Neurosurg Soc. Jul 2020; 63(4): 477-486.

POLICY HISTORY:

Medical Policy Group, September 2003

Medical Policy Administration Committee, October 2003

Available for comment October 20-December 3, 2003

Medical Policy Group, August 2005 (1)

Medical Policy Group, January 2006(1)

Medical Policy Administration Committee, February 2006

Available for comment March 14-April 27, 2006

Medical Policy Group, January 2007 (1)

Medical Policy Group, January 2009 (1)

Medical Policy Group, January 2010 (1)

Medical Policy Group, December 2011 (1): 2012 Updates – Verbiage change to 62287

Medical Policy Group, January 2012 (1): Update to Title, Descriptions, Key Points and References related to endoscopic percutaneous discectomy; no change in policy statement.

Medical Policy Panel, April 2013

Medical Policy Group, September 2013 (2): Policy statement clarified to read “back pain and/or radiculopathy”, all references to open procedures removed, and policy statement specific to Yeung procedure removed.  Title changed to add “Automated”.   Description, Key Points, and References updated to support policy statements.

Medical Policy Administration Committee, September 2013

Available for comments September 19 through November 2, 2013

Medical Policy Panel, March 2014

Medical Policy Group, March 2014 (4): updated Key Points and References. No changes to the policy at this time.

Medical Policy Panel, April 2015

Medical Policy Group, May 2015 (2): 2015 Updates to Key Points and References, no change to policy.

Medical Policy Panel, April 2016

Medical Policy Group, April 2016 (7): 2016 Updates to Key Points and References, no change to policy statement.

Medical Policy Group, December 2016: 2017 Annual Coding Update.  Added new cpt code 62380 to current coding. Updated verbiage for revised CPT code 62287. Updated verbiage for revised cpt code 0274T.

Medical Policy Panel, April 2017

Medical Policy Group, April 2017 (7): Updates to Description, Key Points, Approved by Governing Bodies, and References; added “Percutaneous” to title; added “Percutaneous” to 2nd policy statement. No change in policy intent.

Medical Policy Panel, December 2018

Medical Policy Group, January 2019 (7): Updates to Key Points and References. No change in Policy Statement.

Medical Policy Panel, June 2019

Medical Policy Group, June 2019 (7): Updates to Key Points and References. No change in Policy Statement.

Medical Policy Panel, June 2020

Medical Policy Group, August 2020 (7): Updates to Key Points and References. No change in Policy Statement.

Medical Policy Panel, June 2021

Medical Policy Group, July 2021 (7): Updates to Key Points and References. Removed “not medically necessary” verbiage from Policy Statement. No change in intent.

Medical Policy Panel, June 2022

Medical Policy Group, August 2022 (7): Updates to Key Points and References. No change in Policy Statement.

Medical Policy Panel, June 2023

Medical Policy Group, July 2023 (7): Updates to Key Points, Benefit Application, and References. Clarification to CPT 62287- removed “(e.g., manual or automated percutaneous discectomy, percutaneous laser discectomy).” No change to Policy Statement.

 

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

  1.  The technology must have final approval from the appropriate government regulatory bodies;
  2.  The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
  3.  The technology must improve the net health outcome;
  4.  The technology must be as beneficial as any established alternatives;
  5.  The improvement must be attainable outside the investigational setting.

 

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

  1.  In accordance with generally accepted standards of medical practice; and
  2.  Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
  3.  Not primarily for the convenience of the patient, physician or other health care provider; and
  4.  Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.