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«PacifiCare’s medical management guidelines represent the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. They are ...»

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Professional Societies and Organizations The American Society of Interventional Pain Physicians (ASIPP) states that the evidence is strong and indicates positive short- and long-term outcomes for percutaneous adhesiolysis for the treatment of chronic low back and lower extremity pain.(Boswell, 2005) Their practice guidelines also state that a strong level of evidence indicates that endoscopic epidural adhesiolysis has shortterm efficacy and moderate evidence indicates that it has long-term efficacy; however, for percutaneous and endoscopic adhesiolysis, long-term relief is defined as 3 or more months. (Boswell, 2005) The Royal Australian College of Surgeons (RACS) has stated that although the available literature contains little high-quality evidence of the safety and efficacy of epiduroscopically guided surgery/drug delivery, the available evidence does suggest that epiduroscopy may assist in surgical treatment of back pain in many patients. However, the procedure can worsen pain in a small number of patients. RACS has also stated that accidental dural puncture may occur during epiduroscopy and that further studies are needed to determine the safety and efficacy of this technique relative to other procedures. (RACS, 2003) The National Institute for Health and Clinical Excellence (NICE) has concluded that "current evidence on the safety and efficacy of endoscopic division of epidural adhesions does not appear adequate for this procedure to be used without special arrangements for consent and for audit or research." With regard to consent, the NICE recommends that physicians ensure that patients who want to undergo epidural adhesiolysis understand the uncertainties concerning its efficacy and safety.

(Manchikanti, 2000) References and Resources Resources Bradley WG Jr, Seidenwurm DJ, Brunberg JA, Davis PC, et al. Expert Panel on Neurologic Imaging.

Low back pain. American College of Radiology (ACR); 2005. 7 p. [23 references] Boswell MV, Shah RV, Everett CR, Sehgal N, Brown AM, Abdi S, Bowman RC 2nd, Deer TR, Datta S, Colson JD, Spillane WF, Smith HS, Lucas LF, Burton AW, Chopra P, Staats PS,

Wasserman RA, Manchikanti L. Interventional techniques in the management of chronic spinal pain:

evidence-based practice guidelines. Pain Physician. 2005 Jan;8(1):1-47.

Geurts JW, Kallewaard JW, Richardson J, Groen GJ. Targeted methylprednisolone acetate/hyaluronidase/clonidine injection after diagnostic epiduroscopy for chronic sciatica: a Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography- Commercial Medical Management Guideline prospective, 1-year follow-up study. Reg Anesth Pain Med. 2002;27(4):343-352.

Guyer RD, Ohnmeiss DD; North American Spine Society (NASS). Lumbar discography. The Spine Journal. 2003 May-Jun;3(3):11-27.

Guyer RD, Ohnmeiss DD. Lumbar discography. Position statement from the North American Spine Society Diagnostic and Therapeutic Committee. Spine. 1995 Sep 15;20(18):2048-59.

Hayes Inc. Search & Summary. Functional Anesthetic Discography (FAD) for Diagnosis of Discogenic Pain. Lansdale, PA: Hayes, Inc.; March 11, 2009 Heavner JE, Racz GB, Raj P. Percutaneous epidural neuroplasty: prospective evaluation of 0.9% NaCl versus 10% NaCl with or without hyaluronidase. Reg Anesth Pain Med. 1999;24(3):202-207.

Igarashi T, Hirabayashi Y, Seo N, Saitoh K, Fukuda H, Suzuki H. Lysis of adhesions and epidural injection of steroid/local anaesthetic during epiduroscopy potentially alleviate low back and leg pain in elderly patients with lumbar spinal stenosis. Br J Anaesth. 2004 Aug;93(2):181-7.

Luchs JS, Sofka CM, Adler RS. Sonographic contrast effect of combined steroid and anesthetic injections: in vitro analysis. J Ultrasound Med. 2007 Feb;26(2):227-31.

Manchikanti L, Rivera JJ, Pampati V, et al. Spinal endoscopic adhesiolysis in the management of chronic low back pain: A preliminary report of a randomized, double-blind trial. Pain Physician.

2003;6(3):259-267.

Manchikanti L, Boswell MV, Rivera JJ, Pampati VS, Damron KS, McManus CD, Brandon DE, Wilson SR. [ISRCTN 16558617] A randomized, controlled trial of spinal endoscopic adhesiolysis in chronic refractory low back and lower extremity pain. BMC Anesthesiol. 2005 Jul 6;5:10.

Manchikanti L, Rivera JJ, Pampati V, et. al. One Day Lumbar Epidural Adhesiolysis and Hypertonic Saline Neurolysis in Treatment of Chronic Low Back Pain: A Randomized, Double-Blind Trial. Pain Physician. 2004;7:177-186.

Manchikanti L, Staats P, Singh V, Schultz D, et al. Evidence-Based Practice Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain. Pain Physician. 2003;6:3-81.

Manchikanti L, Pampati V, Fellows B, et al. Role of one day epidural adhesiolysis in management of chronic low back pain: A randomized clinical trial. Pain Physician 2001;4(2):153-166.

Manchikanti L. The value and safety of epidural endoscopic adhesiolysis. AM J Anesthesiol 2000;

275-278.

Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography- Commercial Medical Management Guideline National Institute for Clinical Excellence (NICE) [website]. Endoscopic division of epidural

adhesions. September 2004. Available at:

http://www.nice.org.uk/nicemedia/pdf/ip/IPG088guidance.pdf. Accessed March 31, 2009.

Racz GB, Heavner JE, Trescot A. Percutaneous Lysis of Epidural Adhesions-Evidence for Safety and Efficacy. Pain Pract. 2008 May 23.





Resnick DK, Choudhri TF, Dailey AT, Groff MW, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 6: magnetic resonance imaging and discography for patient selection for lumbar fusion. J Neurosurg: Spine 2:662-669, 2005.

Richardson J, McGurgan P, Cheema S, et al. Spinal endoscopy in chronic low back pain with radiculopathy. A prospective case series. Anaesthesia. 2001;56(5):454-460.

Royal Australian College of Surgeons (RACS) [website]. Australian safety and efficacy register of

new interventional procedures surgical ASERNIPS). Epiduroscopy. June 2003. Available at:

http://www.surgeons.org/AM/Template.cfm?Section=ASERNIP_S_Publications&Template=/CM/ ContentDisplay.cfm&ContentFileID=1819. Accessed March 31, 2009.

Sakai T, Aoki H, Hojo M, Takada M, Murata H, Sumikawa K. Adhesiolysis and targeted steroid/local anesthetic injection during epiduroscopy alleviates pain and reduces sensory nerve dysfunction in patients with chronic sciatica. J Anesth. 2008;22(3):242-7. Epub 2008 Aug 7.

Trescot AM, Chopra P, Abdi S, Datta S, Schultz DM. Systematic review of effectiveness and complications of adhesiolysis in the management of chronic spinal pain: an update. Pain Physician.

2007 Jan;10(1):129-46.

Uchiyama S, Hasegawa K, Homma T, et al. Ultrafine flexible spinal endoscope (myeloscope) and discovery of an unreported subarachnoid lesion. Spine. 1998;23(21):2358-2362.

Veihelmann A, Devens C, Trouillier H, Birkenmaier C, Gerdesmeyer L, Refior HJ. Epidural neuroplasty versus physiotherapy to relieve pain in patients with sciatica: a prospective randomized blinded clinical trial. J Orthop Sci. 2006 Jul;11(4):365-9.

Washington State Health Care Authority (WSHCA). Health Technology Assessment. Spinal Fusion and Discography for Chronic Low Back Pain and Uncomplicated Lumbar Degenerative Disc

Disease. October 19, 2007. Available at:

http://www.hta.hca.wa.gov/documents/spinal_fusion_discography_final_101907.pdf. Accessed March 31, 2009.

Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography- Commercial Medical Management Guideline History/Updates Policy updated and renamed Epiduroscopy, Epidural lysis of Adhesions and Functional 7/1/2009 Anesthetic Discography. Changes to coverage rationale to include functional anesthetic discography. CPT code 64999 added to coding section. Policy 2007T0206F archived.

Policy updated with deletion of code 0026T. Policy 2007T0206E archived.

1/2/2009 6/20/2007 CPT code 0012F removed and 0027T inserted per directions from Coding and Integrity 3/29/2007 CPT codes updated in coding section 1/18/2007 Policy update. Policy combines two former policies: Epiduroscopy (2003T0198C) and Percutaneous Epidural Lysis of Adhesions (2004T0206D) which have been archived.

CMS information updated.

4/12/2005 Reviewed for Medicare Coverage. Medicare Benefit Policy Manual, Ch. 16, Section 20.

Title XVIII of the Social Security Act, section 1862 (a) (1)(A).

6/17/2004 Additional information related to recently published RCT added to Research and Clinical Recommendations sections. No change in unproven coverage determination.

Medicare entry - Title XVIII of the Social Security Act, section 1862 (a) (1)(A). This 6/7/2004 section allows coverage and payment for only those services considered to be reasonable and necessary.

3/24/2004 CPT code 0027T added to the Coding Section per direction from the Reimbursement Medical Policy Operations Manager.

3/18/2004 Yearly update. Additions/revisions in multiple sections. Title enhanced to Percutaneous Epidural Lysis of Adhesions.

3/26/2003 CPT code added.

2/27/2002 Policy Reformatted Contact Information For questions regarding this policy, send an email to the Medical Technology Interpretation Service at medical_drug_interpretation@uhc.com with the word "Medical" in the subject line.

Coding The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only. Listing of a service code in this policy does not imply that the service Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography- Commercial Medical Management Guideline described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.

CPT Codes:

62263 Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days 62264 Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day 64999 Unlisted procedure, nervous system This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation. Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.

Confidential and Proprietary, © UnitedHealthcare, Inc. 2009 Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography- Commercial Medical Management Guideline TITLE: Excimer Laser For Ophthalmic Procedures Authorized By: Medical Management Guideline Committee

Adoption Date: 09/16/09 Revision Date:

Disclaimer This medical management guideline represents the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. It is based on the MMG committee's review of the available evidence as of the date of this medical management guideline.

This medical management guideline contains clinical practice and utilization criteria to assist professionals in PacifiCare’s medical management practice when making medical necessity determinations prior to, subsequent to, or concurrent with the provisions of health care services. This medical management guideline is intended to support consistent, appropriate medical necessity determinations, but it does not replace an individualized case-by-case review and medical necessity determination for each PacifiCare member.

Member benefit coverage and limitations may vary based on the member’s benefit plan.

This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation. Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.

–  –  –

Excimer Laser- Commercial Medical Management Guideline This policy describes the use of ultraviolet light from an excimer laser to ablate corneal tissue for treatment of disorders such as keratoconus, corneal scarring, recurrent erosion, corneal dystrophies, and refractive disorders such as astigmatism. The goal of this procedure is to correct refractive errors and treat corneal disorders with less tissue trauma and better accuracy than can be done with mechanical instruments. This policy also describes the use of computerized corneal topography guided excimer laser ablation to treat visual problems.

Coverage All reviewers must first identify member eligibility, any federal or state regulatory requirements and the plan benefit coverage prior to use of this policy.

Coverage Rationale Excimer Laser Phototherapeutic Keratectomy (PTK) Excimer laser phototherapeutic keratectomy (PTK) is proven for the treatment of the following

conditions:

- corneal scars,

- corneal dystrophies,

- corneal degeneration,

- band keratopathy,

- contact lens-induced keratopathy, and



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