Local Coverage Determination for Endoscopic and ...

1 Local Coverage Determination (LCD) for Endoscopic andPercutaneous lysis of epidural Adhesions (L29256)Contractor InformationContractor NameFirst Coast Service Options, Number09102 Contractor TypeMAC - Part BBack to TopLCD InformationDocument InformationLCD ID NumberL29256 LCD TitleEndoscopic and percutaneous lysis ofEpidural AdhesionsContractor's Determination Number62263 AMA CPT/ADA CDT Copyright StatementCPT codes, descriptions and other data onlyare copyright 2011 American MedicalAssociation (or such other date of publicationof CPT). All Rights Reserved. ApplicableFARS/DFARS Clauses Apply. Current DentalTerminology, (CDT) (including procedurecodes, nomenclature, descriptors and otherdata contained therein) is copyright by theAmerican Dental Association. 2002, 2004 American Dental Association. All rightsreserved.

2 Applicable FARS/DFARS Geographic JurisdictionFloridaOversight RegionRegion IVOriginal Determination Effective DateFor services performed on or after 02/02/2009 Original Determination Ending DateRevision Effective DateFor services performed on or after 10/01/2010 Revision Ending DateCMS National Coverage PolicyLanguage quoted from CMS National Coverage Determinations (NCDs) and coverageprovisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and Coverage provisions in interpretive manuals are not subject to the LCDR eview Process (42 CFR [b] and 42 CFR 426 [Subpart D]). In addition, anadministratice law judge may not review an NCD. See 1869(f)(1)(A)(i) of the Social otherwise specified, italicized text represents quotation from one or more of thefollowing CMS sources:Printed on 2/3/2012.

3 Page 1 of 6 N/AIndications and Limitations of Coverage and/or Medical NecessityEndoscopic epidural lysis of adhesions (also known as Endoscopic lysis ) and percutaneousepidural lysis of adhesions (also referred to as epidural neuroplasty or epidural adhesiolysis)are interventional pain management techniques that are used to treat chronic cervical,lumbar, and thoracic pain. The basis for performing this procedure is the premise that fibrousadhesions (scar tissue) develops after surgery, trauma, and/or inflammation that compoundspain associated with the nerve root by fixing it in one position and thus increasing thesusceptibility of the nerve root to tension or compression. This scar tissue also prevents thedirect application of medications to relieve pain ( Local anesthetics and corticosteroids) to theproblem area. The goal of the procedure is to break down these fibrous adhesions to allowfor delivery of high concentrations of injected drugs to the target area and free the nerve frommechanical tension/compression.

4 The procedure usually involves adhesiolysis proceduresperformed over a 1-3 day period (CPT code 62263 more than 2 days or 62264 one day).Adhesiolysis can be accomplished by solution injection (commonly hypertonic saline and/orhyaluronidase) and/or by mechanical means (by maneuvering a specially designed epiduralcatheter or epiduroscope).Medicare will consider the use of Endoscopic and percutaneous lysis of epidural adhesions tobe medically reasonable and necessary in the treatment of chronic refractory cervical,lumbar, and thoracic pain that has failed to respond to more conservative treatmentmeasures. Conservative treatment may include Local heat, traction, nonsteroidal anti-inflammatory medications, and anesthetic and/or steroid epidural injections. The chronicrefractory low back pain may be secondary to post lumbar laminectomy syndrome,intervertebral lumbar disc disruption, lumbar epidural adhesions, and/or lumbar degenerativedisc disorder.

5 It is not expected that services will exceed one every six months to the sameanatomical region. Services exceeding one every six months may be subject to to TopCoding InformationBill Type Codes:Contractors may specify Bill Types to help providers identify those Bill Types typically used toreport this service. Absence of a Bill Type does not guarantee that the policy does not applyto that Bill Type. Complete absence of all Bill Types indicates that Coverage is not influencedby Bill Type and the policy should be assumed to apply equally to all ApplicableRevenue Codes:Printed on 2/3/2012. Page 2 of 6 Contractors may specify Revenue Codes to help providers identify those Revenue Codestypically used to report this service. In most instances Revenue Codes are purely advisory;unless specified in the policy services reported under other Revenue Codes are equallysubject to this Coverage Determination .

6 Complete absence of all Revenue Codes indicatesthat Coverage is not influenced by Revenue Code and the policy should be assumed to applyequally to all Revenue ApplicableCPT/HCPCS CodesGroupName64999 Unlisted procedure, nervous system ( Endoscopic lysis of epidural adhesionswith the epiduroscope)62263 percutaneous lysis OF epidural ADHESIONS USINGSOLUTION INJECTION (EG, HYPERTONIC SALINE, ENZYME) ORMECHANICAL MEANS (EG, CATHETER) INCLUDING RADIOLOGICLOCALIZATION (INCLUDES CONTRAST WHEN ADMINISTERED),MULTIPLE ADHESIOLYSIS SESSIONS; 2 OR MORE DAYS62264 percutaneous lysis OF epidural ADHESIONS USINGSOLUTION INJECTION (EG, HYPERTONIC SALINE, ENZYME) ORMECHANICAL MEANS (EG, CATHETER) INCLUDING RADIOLOGICLOCALIZATION (INCLUDES CONTRAST WHEN ADMINISTERED),MULTIPLE ADHESIOLYSIS SESSIONS; 1 DAY64999 UNLISTED PROCEDURE, NERVOUS SYSTEMICD-9 Codes that Support Medical OF CERVICAL INTERVERTEBRAL DISC OF LUMBAR INTERVERTEBRAL DISC OF CERVICAL INTERVERTEBRAL OF LUMBAR OR LUMBOSACRALINTERVERTEBRAL DISC DISORDER WITH MYELOPATHY SYNDROME OF CERVICAL SYNDROME OF THORACIC SYNDROME OF LUMBAR STENOSIS IN CERVICAL NEURITIS OR RADICULITIS STENOSIS OF THORACIC STENOSIS, LUMBAR REGION, WITHOUT NEUROGENICCLAUDICATIONP rinted on 2/3/2012.

7 Page 3 of 6 STENOSIS, LUMBAR REGION, WITH OR LUMBOSACRAL NEURITIS OR RADICULITISUNSPECIFIEDD iagnoses that Support Medical NecessityN/AICD-9 Codes that DO NOT Support Medical NecessityN/AICD-9 Codes that DO NOT Support Medical Necessity Asterisk ExplanationDiagnoses that DO NOT Support Medical NecessityN/ABack to TopGeneral InformationDocumentations RequirementsMedical record documentation maintained by the performing physician must clearly indicate the medicalnecessity of the service being billed. In addition, documentation that the service was performed must beincluded in the patient s medical record. This information is normally found in the office/progress notes,hospital notes, and/or procedure addition, the medical record should clearly document the nature of the cervical, lumbar, or thoracicpain. This should include the location, intensity, type of pain present, and contributing factors (if any),duration of condition, and treatment regimes that have been utilized.

8 Documentation should demonstratefailure of more conservative management in the treatment of the patient s condition. This moreconservative treatment may include Local heat, traction, nonsteroidal anti-inflammatory medications, andanesthetic and/or steroid epidural Utilization Guidelines It is expected that these services would be performed as indicated by currentmedical literature and/or standards of practice. When services are performed in excess of establishedparameters, they may be subject to review for medical necessity. Sources of Information and Basis for DecisionBoswell, M. V., Trescot, A. M., et al Interventional techniques: evidence-based practice guidelines in themanagement of chronic spinal pain. Pain Physician 10:7 pp , l., Heavner, J., Boswell, (2007) Endoscopic lumbar epidural adhesions. InterventialTechniques in Chronic Spinal Pain.

9 Pp 507-526 Manchikanti, L., Boswell, , et al. A randomized controlled trial of spinal Endoscopic adhesiolysis inchronic refractory low back and lower extremity pain. BMC Anesthesiology 2005 (5) 10 Manchikanti, L., Singh, V (2007) Pecutaneous lysis of lumbar epidural adhesions. InterventionalTechniques in Chronic Spinal Pain. Pp479-506 Printed on 2/3/2012. Page 4 of 6 Racz, , Heavner, , Trescot, A. (2008) percutaneous lysis of epidural adhesions-evidence for safetyand efficacy. Pain Practice 8 (4) , Chopra P., Abdi S., Datta S., Schultz Systematic review of effectiveness andcomplications of adhesiolysis in the management of chronic spinal pain: An update. Pain Physician 2007;10: 129-146. ;10; Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect thesole opinion of the contractor or Contractor Medical Director.

10 Although the final decision rests with thecontractor, this LCD was developed in cooperation with advisory groups, which includes representativesfrom numerous Contractor Advisory Committee Meeting held on June 20, 2009. Start Date of Comment Period End Date of Comment Period Start Date of Notice Period 10/01/2010 Revision History Number 2 Revision History Explanation Revision Number: 2 Start Date of Comment Period:N/AStart Date of Notice Period:10/01/2010 Revised Effective Date: 10/01/2010 LCR B2010-071 September 2010 UpdateExplanation of Revision: Annual 2011 ICD-9-CM Update. Added ICD-9-CM code Reviseddescriptor for ICD-9-CM code The effective date of this revision is based on date of Number:1 Start Date of Comment Period:06/01/2009 Start Date of Notice Period:08/15/2009 Revised Effective Date: 09/30/2009 LCR B2009-087 August 2009 UpdateExplanation of Revision: LCD revised to include Endoscopic lysis of epidural adhesions.