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

-- [ Page 88 ] --

Discogenic Pain, Treatment - Commercial Medical Management Guideline Lutz C, Lutz GE, and Cooke PM. Treatment of chronic lumbar diskogenic pain with intradiskal electrothermal therapy: A prospective outcome study. Arch Phys Med Rehabil. 2003(Jan.);84(1):23-8.

Marin FZ. CAM versus nucleoplasty. Acta Neurochir Suppl. 2005;92:111-114.

Masala S, Massari F, Fabiano S, et al. Nucleoplasty in the treatment of lumbar diskogenic back pain: one year follow-up.

Cardiovasc Intervent Radiol. 2007;30(3):426-432.

McMillan MR, Patterson PA, Parker V. Percutaneous laser disc decompression for the treatment of discogenic lumbar pain and sciatica: a preliminary report with 3-month follow-up in a general pain clinic population. Photomed Laser Surg.

2004 Oct;22(5):434-8.

Mirzai H, Tekin I, Yaman O, Bursali A. The results of nucleoplasty in patients with lumbar herniated disc: a prospective clinical study of 52 consecutive patients. Spine J. 2007;7(1):88-93.

Mochida J, Toh E, Nomura T, Nishimura K. The risks and benefits of percutaneous nucleotomy for lumbar disc herniation. A 10-year longitudinal study. J Bone Joint Surg Br. 2001;83(4):501-505.

Nardi PV, Cabezas D, Cesaroni A. Percutaneous cervical nucleoplasty using coblation technology. Clinical results in fifty consecutive cases. Acta Neurochir Suppl. 2005;92:73-78.

National Institute for Clinical Excellence (NICE). Interventional Procedures Percutaneous intradiscal thermocoagulation

for lower back pain. Guidance Issue date: August 2004.available at:

http://www.nice.org.uk/nicemedia/pdf/ip/IPG083guidance.pdf. Accessed March 2009.

National Institute for Health and Clinical Excellence (NICE). Percutaneous disc decompression using coblation for lower

back pain. Interventional Procedures Consultation Document. London, UK: NICE; 24 May 2004. Available at:

http://www.nice.org.uk/Guidance/IPG173. Accessed March 2009.

National Institute for Health and Clinical Excellence (NICE). Percutaneous intradiscal electrothermal therapy for lower back pain. Available at: http://www.nice.org.uk/Guidance/IPG81. Accessed March 2009.

Ohnmeiss DD, Guyer RD, Hochschuler SH. Laser disc decompression. The importance of proper patient selection. Spine.

1994;19(18):2054-2059.

Pauza KJ, Howell S, Dreyfuss P, et al. A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain. Spine J. 2004 Jan-Feb;4(1):27-35.

Saal, J., and Saal, J. Management of chronic discogenic low back pain with a thermal intradiscal catheter. Spine.

2000a(Feb.);25(3): 382-388.

Saal, J., and Saal, J. Intradiscal electrothermal treatment for chronic discogenic low back pain: a prospective study with minimum one-year follow-up. Spine. 2000b(Nov.);25(20): 2622-2627.

Sharps L and Isaac Z. Percutaneous disc decompression using nucleoplasty. Pain Physician. 2002;5(2):121-126.

Singh V, Piryani C, Liao K. Evaluation of percutaneous disc decompression using coblation in chronic back pain with or without leg pain. Pain Phys. 2003;6:273-280.

Discogenic Pain, Treatment - Commercial Medical Management Guideline Tassi GP. Preliminary Italian experience of lumbar spine percutaneous laser disc decompression according to Choy's method. Photomed Laser Surg. 2004 Oct;22(5):439-41.

Toyone T, Tanaka T, Kato D, et al. Low-back pain following surgery for lumbar disc herniation. A prospective study. J Bone Joint Surg Am. 2004 May;86-A(5):893-6.

Tsou PM, Alan Yeung C, Yeung AT. Posterolateral transforaminal selective endoscopic discectomy and thermal annuloplasty for chronic lumbar discogenic pain: a minimal access visualized intradiscal surgical procedure. Spine J.

2004;4(5):564-73.

Urrutia G, Kovacs F, Nishishinya MB, Olabe J. Percutaneous thermocoagulation intradiscal techniques for discogenic low back pain. Spine. 2007 May 1;32(10):1146-54.

Whitlow CT, Mussat-Whitlow BJ, Mattern CW, et al. Sacroplasty versus vertebroplasty: comparable clinical outcomes

for the treatment of fracture-related pain. AJNR Am J Neuroradiol. 2007;28(7):1266-1270. Available at:

http://www.ajnr.org/cgi/content/full/28/7/1266. Accessed June 2009.

Yakovlev A, Tamimi MA, Liang H, Eristavi M. Outcomes of percutaneous disc decompression utilizing nucleoplasty for the treatment of chronic discogenic pain. Pain Physician. 2007;10(2):319-328.

History/Updates Policy revised and renamed Discogenic Pain, Treatment. CMS information updated. Policy Nonsurgical 9/1/20 Intradiscal Procedures for Discogenic Pain (2009T0105F) archived.

Policy revision with changes to the coverage rationale. Policy renamed Nonsurgical Intradiscal Procedures for 8/13/2 Discogenic Pain. CMS information updated. Deleted CPT code 62267 from the coding section. Added procedure codes 62287, S2348, 0200T, and 0201T to the coding section. Policy, Electrothermal Therapy for Discogenic Pain (2008T0105E) archived.

Policy revision with changes to the coverage rationale to include biacuplasty. CMS section updated. CPT code 1/2/20 01936 removed from the coding section. Policy 2007T0105D archived.

2/15/2 CPT code 01936 added to policy per Manager, Coding and Integrity.

CPT codes 22526 and 22527 added and HCPCS codes S2370 and S2371 removed from Coding Section per 2/27/2 direction from Reimbursement Medical Policy Operations Manager.





1/18/2 Update and combined policies. This is a new name. Updated CMS. Archived 2003T0105C and 2004T0303D.

Policy update that combines Intradiscal Electrothermal Therapy for Discogenic Pain 2003T0105C and 12/5/2 Nucleoplasty 2004T0303D.

CPT codes 0062T, 0063T and HCPCS codes S2370, S2371 added to Coding Section per direction from the 7/30/2 Reimbursement Medical Policy Operations Manager.

9/5/20 Medicare Entry Discogenic Pain, Treatment - Commercial Medical Management Guideline

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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 described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.

CPT Code Section 0062 Percutaneous intradiscal annuloplasty, any method except electrothermal, unilateral or bilateral including T fluoroscopic guidance; single level 0063 Percutaneous intradiscal annuloplasty, any method except electrothermal, unilateral or bilateral including T fluoroscopic guidance; 1 or more additional levels (List separately in addition to 0062T for primary procedure) 0200 Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or T mechanical device (if utilized), one or more needles 0201 Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical T device (if utilized), two or more needles 2252 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance;

6 single level 2252 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; one 7 or more additional levels (List separately in addition to code for primary procedure) 6228 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method, single or 7 multiple levels, lumbar (eg, manual or automated percutaneous discectomy, percutaneous laser discectomy) HCPCS Code Section S234 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, 8 single or multiple levels, lumbar 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 Discogenic Pain, Treatment - Commercial Medical Management Guideline 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 Discogenic Pain, Treatment - Commercial Medical Management Guideline TITLE: Dysfunctional Uterine Bleeding and Uterine Fibroids 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.

–  –  –

Description After evaluating relevant benefit document language (exclusions or limitations), refer to Coverage sections of this document to determine coverage.

This policy describes minimally invasive treatments used to treat uterine fibroids and reduce excessive blood loss in women with abnormal uterine bleeding.

Dysfunctional Uterine Bleeding and Uterine Fibroids- Commercial Medical Management Guideline 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 Endometrial Ablation Endometrial cryoablation (ECA) is proven for the treatment of menorrhagia in premenopausal women.

Thermal balloon endometrial ablation (TBEA) and hydrothermal endometrial ablation (HTEA) are proven for the treatment of menorrhagia in premenopausal patients.

Radiofrequency endometrial ablation (NovaSureTM) is proven for the treatment of menorrhagia in premenopausal women.

Magnetic resonance imaging (MRI)-guided cryoablation is unproven for the treatment of uterine fibroids.

The published evidence on MRI- guided cryoablation for the treatment of fibroids consists of a manufacturer-sponsored clinical trial of a very small population. Further long-term studies on larger samples published in peer-reviewed medical literature are necessary to prove the safety and efficacy of this technology.

Magnetic resonance imaging (MRI)-guided focused ultrasound ablation (FUA) is unproven for the treatment of uterine fibroids.

Results of two prospective case series suggest that this procedure can reduce fibroid volume and improve symptoms over the short term. However, limitations of these studies include short follow-up, no comparison of FUA to other minimally invasive technologies intended to treat uterine fibroids and preserve uterine structure and function, the subjective nature, measurement, and interpretation of principal outcomes, small sample size, and the incomplete reporting of results. (Please refer to the Benefit Considerations section for potential coverage of unproven services.) Levonorgestrel-Releasing Intrauterine Device The levonorgestrel-releasing intrauterine device (LNG-IUD) is proven for the treatment of dysfunctional uterine bleeding in premenopausal women.

Uterine Artery Embolization Uterine artery embolization (UAE) is proven for the treatment of confirmed, symptomatic uterine fibroids.

Additional clinical recommendations for the use of uterine artery embolization include:

- Presence of symptomatic myomata or leiomyomata, including menorrhagia and pain

- Failed pharmacotherapy, unless patient cannot tolerate pharmacotherapy There is an expectation that other causes of menorrhagia and pain have been ruled out and the interventional radiologist will explain the advantages and harms of uterine artery embolization and the availability of alternate treatments, including myomectomy.

Uterine artery embolization (UAE) is unproven for women with symptomatic uterine fibroids who wish to preserve their childbearing potential.

The effects of UAE on ovarian and uterine function and on fertility are relatively unknown. Further studies of safety and/or efficacy in published, peer-reviewed medical literature are necessary.

Regulatory Requirements

U.S. Food and Drug Administration (FDA):



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