Clinical UM Guideline

 

Subject: Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy
Guideline #:  CG-SURG-38 Publish Date:    08/29/2018
Status: Reviewed Last Review Date:    07/26/2018

Description

This document addresses laminectomy, hemi-laminectomy, laminotomy and discectomy as a means to surgically manage various lumbar conditions.

A lumbar laminectomy is a surgical procedure which involves the removal of a portion of the bony arch, or lamina, on the dorsal surface of a vertebra.  The procedure is performed to relieve pressure on the nerve roots and spinal cord.  The most common reason for performing a laminectomy is to treat spinal stenosis which is a chronic narrowing of the spinal canal due to degenerative arthritis and disc degeneration.  If only one side is removed, it is called a hemilaminectomy.  It is not uncommon for a laminectomy to be performed in combination with other surgical procedures such as discectomy (diskectomy), foraminotomy, spinal fusion or excision of an intraspinal tumor or lesion.  In most cases a laminectomy is performed as an elective procedure rather than as emergency surgery.

Note: For information regarding other spinal procedures, see:

Clinical Indications

Medically Necessary:

Note: When procedure is performed using a percutaneous or endoscopic approach (as opposed to an open approach with direct visualization), refer to SURG.00071 Percutaneous and Endoscopic Spinal Surgery.

Lumbar laminectomy, hemilaminectomy, laminotomy (for unilateral symptoms), and/or discectomy is considered medically necessary when at least one of the following criteria is met:

  1. Conus medullaris syndrome (spinal cord compression) confirmed by appropriate imaging studies with severe or progressive neurologic deficits consistent with spinal cord compression (for example, fecal or urinary incontinence); or
  2. Cauda equina syndrome with neurologic deficits (bowel or bladder dysfunction, saddle anesthesia, bilateral neurologic abnormalities of the lower extremities) confirmed by physical examination and appropriate imaging studies; or
  3. Lumbar spinal stenosis and/or foraminal stenosis confirmed by appropriate imaging studies, with either:
    1. severe and progressive symptoms of pain or neurogenic claudication (buttock or leg) unresponsive to at least 6 weeks of conservative nonoperative therapy; or
    2. significant motor deficit preventing ambulation; or
  4. Lumbar herniated intervertebral disc with nerve root compression confirmed by appropriate imaging studies and the following additional criteria are met:
    1. Radicular pain with physical findings of nerve compression (for example, absent lower extremity reflex or loss of sensation in dermatomal distribution) or alternative clinical findings consistent with radiculopathy; and
    2. All other reasonable sources of pain have been ruled out; and
    3. Findings on imaging correspond to the clinical findings and neurological examination; and
    4. Symptoms are interfering with either:
      1. functional activities of daily living and persist despite at least 6 weeks of conservative nonoperative therapy; or
      2. are associated with significant or progressive motor deficits; or
  5. When performed with dorsal rhizotomy as a treatment for spasticity (for example, cerebral palsy); or
  6. When performed with biopsy or excision when signs or symptoms indicative of lumbar disease (for example, pain, motor weakness) and imaging suggests tumor or metastatic neoplasm, an infectious process (for example, epidural abscess), arteriovenous malformation, malignant or non-malignant mass; or
  7. Acute fracture causing symptomatic nerve root compression.

Note: Conservative non-operative therapy consists of an appropriate combination of medication (for example, Non-Steroidal Anti-Inflammatory Drugs [NSAIDs], analgesics), physical therapy, spinal manipulation therapy, epidural steroid injections, or other interventions based on the individual’s specific presentation, physical findings and imaging results.

Not Medically Necessary:

Lumbar laminectomy is considered not medically necessary when criteria above are not met and for all other indications not listed above as medically necessary.

Lumbar hemilaminectomy is considered not medically necessary when criteria above are not met and for all other indications not listed above as medically necessary.

Lumbar laminotomy is considered not medically necessary when criteria above are not met and for all other indications not listed above as medically necessary.

Lumbar discectomy is considered not medically necessary when criteria above are not met and for all other indications not listed above as medically necessary.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

63005

Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis) 1 or 2 vertebral segments; lumbar, except for spondylolisthesis

63012

Laminectomy with removal of abnormal facets and/or pars interarticularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)

63017

Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar

63030

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar

63035

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar [when specified as lumbar]

63042

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, re-exploration, single interspace; lumbar

63044

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, re-exploration, single interspace; each additional lumbar interspace

63047

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar

63048

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar [when specified as lumbar]

63056

Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)

63057

Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar [when specified as lumbar]

63185

Laminectomy with rhizotomy; 1 or 2 segments [when specified as lumbar]

63190

Laminectomy with rhizotomy; more than 2 segments [when specified as lumbar]

63200

Laminectomy, with release of tethered spinal cord, lumbar

63252

Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar

63267

Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar

63272

Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar

63277

Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar

63282

Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar

63287

Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracolumbar

63290

Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural lesion, any level [when specified as lumbar]

 

 

ICD-10 Procedure

 

008Y0ZZ

Division of lumbar spinal cord, open approach

008Y4ZZ

Division of lumbar spinal cord, percutaneous endoscopic approach

009Y00Z

Drainage of lumbar spinal cord with drainage device, open approach

009Y0ZZ

Drainage of lumbar spinal cord, open approach

009Y40Z

Drainage of lumbar spinal cord with drainage device, percutaneous endoscopic approach

009Y4ZZ

Drainage of lumbar spinal cord, percutaneous endoscopic approach

00BY0ZZ

Excision of lumbar spinal cord, open approach

00BY4ZZ

Excision of lumbar spinal cord, percutaneous endoscopic approach

00NY0ZZ

Release lumbar spinal cord, open approach

00NY4ZZ

Release lumbar spinal cord, percutaneous endoscopic approach

018B0ZZ

Division of lumbar nerve, open approach

018B4ZZ

Division of lumbar nerve, percutaneous endoscopic approach

0SB00ZZ

Excision of lumbar vertebral joint, open approach

0SB04ZZ

Excision of lumbar vertebral joint, percutaneous endoscopic approach

0SB20ZZ

Excision of lumbar vertebral disc, open approach

0SB24ZZ

Excision of lumbar vertebral disc, percutaneous endoscopic approach

0SB30ZZ

Excision of lumbosacral joint, open approach

0SB34ZZ

Excision of lumbosacral joint, percutaneous endoscopic approach

0SB40ZZ

Excision of lumbosacral disc, open approach

0SB44ZZ

Excision of lumbosacral disc, percutaneous endoscopic approach

0SN00ZZ

Release lumbar vertebral joint, open approach

0SN04ZZ

Release lumbar vertebral joint, percutaneous endoscopic approach

0SN20ZZ

Release lumbar vertebral disc, open approach

0SN24ZZ

Release lumbar vertebral disc, percutaneous endoscopic approach

0SN30ZZ

Release lumbosacral joint, open approach

0SN34ZZ

Release lumbosacral joint, percutaneous endoscopic approach

0SN40ZZ

Release lumbosacral disc, open approach

0SN44ZZ

Release lumbosacral disc, percutaneous endoscopic approach

0ST20ZZ

Resection of lumbar vertebral disc, open approach

0ST40ZZ

Resection of lumbosacral disc, open approach

 

 

ICD-10 Diagnosis

 

C41.2

Malignant neoplasm of vertebral column

C70.1

Malignant neoplasm of spinal meninges

C72.0-C72.1

Malignant neoplasm of spinal cord, cauda equina

C79.49

Secondary malignant neoplasm of other parts of nervous system

D16.6

Benign neoplasm of vertebral column

D32.1

Benign neoplasm of spinal meninges

D33.4

Benign neoplasm of spinal cord

D42.1

Neoplasm of uncertain behavior of spinal meninges

D43.4

Neoplasm of uncertain behavior of spinal cord

G06.1

Intraspinal abscess and granuloma

G80.0-G80.9

Cerebral palsy

G82.20-G82.22

Paraplegia

G83.4

Cauda equina syndrome

K59.2

Neurogenic bowel, not elsewhere classified

M08.1

Juvenile ankylosing spondylitis

M43.06-M43.07

Spondylolysis, lumbar/lumbosacral regions

M43.16-M43.17

Spondylolisthesis, lumbar/lumbosacral regions

M45.6-M45.7

Ankylosing spondylitis, lumbar/lumbosacral regions

M47.16-M47.17

Other spondylosis with myelopathy, lumbar/lumbosacral regions

M47.26-M47.27

Other spondylosis with radiculopathy, lumbar/lumbosacral regions

M47.816-M47.817

Spondylosis without myelopathy or radiculopathy, lumbar/lumbosacral regions

M47.896-M47.897

Other spondylosis, lumbar/lumbosacral regions

M48.061-M48.07

Spinal stenosis, lumbar/lumbosacral regions

M48.36-M48.37

Traumatic spondylopathy, lumbar/lumbosacral regions

M48.8X6-M48.8X7

Other specified spondylopathies, lumbar/lumbosacral regions

M51.06-M51.07

Intervertebral disc disorders with myelopathy, lumbar/lumbosacral regions

M51.16-M51.17

Intervertebral disc disorders with radiculopathy, lumbar/lumbosacral regions

M51.26-M51.27

Other intervertebral disc displacement, lumbar/lumbosacral regions

M51.36-M51.37

Other intervertebral disc degeneration, lumbar/lumbosacral regions

M51.46-M51.47

Schmorl’s nodes, lumbar/lumbosacral regions

M51.86-M51.87

Other intervertebral disc disorders, lumbar/lumbosacral regions

M54.16-M54.17

Radiculopathy, lumbar/lumbosacral regions

M54.30-M54.32

Sciatica

M54.40-M54.42

Lumbago with sciatica

M54.5

Low back pain

M54.9

Dorsalgia, unspecified

M96.1

Postlaminectomy syndrome, not elsewhere classified

Q27.39

Arteriovenous malformation, other site

Q76.2

Congenital spondylolisthesis

S32.000A-S32.059S

Fracture of lumbar vertebra

S34.21XA-S34.21XS

Injury of nerve root of lumbar spine

Discussion/General Information

Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy

Lumbar laminectomy, hemilaminectomy, laminotomy and discectomy are established surgical options for several conditions when symptoms persist despite noninvasive treatment (when conservative management is appropriate) or as first line treatment for certain emergencies.  Several specialty associations/societies have published guidelines which provide criteria for when lumbar laminectomy, hemilaminectomy, laminotomy and/or discectomy is considered an appropriate surgical intervention.  There are also numerous peer-reviewed articles that discuss the pros and cons of these procedures.

As with all surgical procedures, lumbar surgery is not without risk.  It has been reported that dural tears occur in approximately 10% of individuals undergoing laminectomy, and neurologic injuries may occur in about 2.5%.  The American Pain Society (APS) guidelines on interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain recommended that clinicians discuss the risks and benefits of surgery as an "Option" (that is, strong recommendation, high-quality evidence).  It is further recommended that shared decision-making regarding surgery include a specific discussion about moderate/average benefits, which appear to decrease over time in affected individuals who undergo surgery (Chou, 2009).

The North American Spine Society (NASS) “Coverage Policy Recommendations” provide clinical indications for several spine procedures including, but not limited to lumbar laminotomy and lumbar discectomy.  According to information on the NASS website, the Coverage Policy Recommendations were created using “an evidence-based approach to spinal care when possible.  In the absence of strict evidence-based criteria, policies reflect the multidisciplinary and non-conflicted experience and expertise of the authors in order to reflect reasonable standard practice indications in the United States”  The authors also state that the coverage recommendations are not representative of a “standard of care” and should not be viewed as “fixed treatment protocols” (NASS, 2014a; NASS, 2014b).

Low Back Pain

The APS recommends that in instances where conservative management fails to relieve symptoms of radiculopathy and there is strong evidence of dysfunction of a specific nerve root confirmed at the corresponding level by CT or MRI, further evaluation and more invasive treatment, including spine surgery, may be proposed as a treatment option (Chou, 2009).

According to the Washington State Department of Labor and Industries guidelines which provide criteria for single lumbar nerve root entrapment, lumbar laminectomy is appropriate for individuals who failed to respond to treatment after a minimum of four weeks of conservative therapy and have both objective and subjective findings of lumbar nerve root entrapment (Washington State, 1999).

Lumbar Disc (Herniated Intervertebral Disc)

Most instances of lumbar disc herniations will respond positively to conservative management and will not require surgical treatment.  However, some individuals may have severe, unremitting pain that requires more immediate intervention.

The Spine Patient Outcomes Research Trial (SPORT) was funded by the National Institutes of Health (NIH) to study the outcomes from surgical and nonsurgical management of three conditions: intervertebral disc herniation, degenerative spondylolisthesis, and lumbar spinal stenosis.  Both surgical and nonsurgical care of intervertebral disc herniation resulted in significant improvement in symptoms of low back and leg pain.  However, the treatment effect of surgery for intervertebral disc herniation was less than that seen in individuals with degenerative spondylolisthesis and lumbar spinal stenosis.  The preliminary 4-year outcomes data demonstrated more significant degrees of improvement in pain levels and function with surgical versus nonsurgical treatment in the chronic conditions of lumbar spinal stenosis and lumbar spinal stenosis with spondylolisthesis (Asghar, 2012; Weinstein, 2006a; Weinstein, 2006b; Weinstein, 2007; Weinstein, 2009).

According to the APS, decompressive laminectomy may be an acceptable option for individuals experiencing disabling and persistent leg pain due to spinal stenosis, either with or without degenerative spondylolisthesis.  The APS reports that decompressive laminectomy is associated with moderate benefits compared to nonsurgical therapy through 1 to 2 years, though the effects of the procedure appear to diminish with long-term follow-up.  Although individuals on average do not worsen without surgery, improvements are less than those observed in individuals with radiculopathy due to herniated lumbar disc.  Their guidelines indicate there is insufficient evidence to determine if laminectomy with fusion is more effective than laminectomy without fusion.  The authors recommended that shared decision-making regarding surgery include a specific discussion about moderate/average benefits, which appear to decrease over time in affected individuals who undergo surgery (Chou, 2009).

Lumbar Spinal Stenosis and/or Foraminal Stenosis

NASS (2013) published evidence-based guidelines on the diagnosis and treatment of degenerative lumbar spinal stenosis.  NASS found that in the absence of evidence for or against any specific treatment, it is the work group’s recommendation that medical/interventional treatment be considered for individuals with mild symptoms of lumbar spinal stenosis (Kreiner, 2013).

As mentioned above, the SPORT trial explored the outcomes from surgical and nonsurgical management of intervertebral disc herniation, degenerative spondylolisthesis, and lumbar spinal stenosis.  The preliminary 4-year outcomes data demonstrated more significant degrees of improvement in pain levels and function with surgical versus nonsurgical treatment in the chronic conditions of lumbar spinal stenosis and lumbar spinal stenosis with spondylolisthesis (Asghar, 2012; Weinstein, 2006a; Weinstein, 2006b; Weinstein, 2007; Weinstein, 2009; Weinstein, 2010).

Lumbar Spondylolisthesis

According to NASS evidence-based guidelines on the diagnosis and treatment of degenerative lumbar spondylolisthesis, the purpose of the guidelines is to address key clinical questions surrounding the diagnosis and treatment of degenerative lumbar spondylolisthesis.  The group assigned a “B” rating to the consensus statement that surgery be recommended for individuals with symptomatic spinal stenosis associated with low grade degenerative spondylolisthesis whose symptoms have been recalcitrant to a trial of medical/interventional treatment.  The group also issued a statement that there is insufficient evidence to support the use of direct or indirect surgical decompression for the treatment of individuals with symptomatic spinal stenosis associated with low grade degenerative lumbar spondylolisthesis whose symptoms have been recalcitrant to a trial of medical/interventional treatment (Watters, 2008).

According to the SPORT trial investigation (see above), the outcomes data demonstrated more significant degrees of improvement in pain levels and function with surgical versus nonsurgical treatment in the chronic conditions of lumbar spinal stenosis and lumbar spinal stenosis with spondylolisthesis (Asghar, 2012; Weinstein, 2006a; Weinstein, 2006b; Weinstein, 2007; Weinstein, 2009; Weinstein, 2010).

Definitions

Cauda equina (horse’s tail) syndrome: A condition which results from the compression of multiple dorsal and ventral nerve roots in the lumbar spinal canal, usually as a result of a large central herniated disc.

Discectomy: The partial or complete removal of an intervertebral disc.

Hemilaminectomy: A surgical procedure in which the lamina is removed on one side of the vertebrae.

Herniated disc: A condition in which a portion of the nucleus pulposus extends through the annulus (the outer disc layers). Herniated discs may additionally be classified as: contained (there is still a retained thin outer layer of annulus or ligament), extruded (the nuclear material extends into the spinal canal) or sequestrated (when a herniated fragment migrates away from the disc).

Lamina: The part of the vertebra that forms the roof of the spinal canal.

Laminectomy: A spine operation to remove all or a portion of the roof of the spinal canal; frequently performed to decompress the neural elements.

Laminotomy: A spine operation in which the lamina is partially removed.

Radiculopathy: Any disease of the spinal nerve roots and spinal nerves; radiculopathy is characterized by pain which seems to radiate from the spine to extend outward to cause symptoms away from the source of the spinal nerve root irritation; causes of radiculopathy include deformities of the discs between the building blocks of the spine (the vertebrae).

Spine anatomy: The spine is divided into three major sections: the cervical (neck), the thoracic (mid-back) and lumbar spine (lower back). These sections are made up of individual bones called vertebrae, which are the primary weight bearing structures of the torso alternating with intervertebral discs.

Spinal stenosis: A chronic narrowing of the spinal canal due to degenerative arthritis and disc degeneration.

Spondylolisthesis: Forward slippage of one vertebral body with impingement upon the adjacent inferior disc.

Vertebrae: Bones that make up the spinal column which surround and protect the spinal cord.

References

Peer Reviewed Publications:

  1. Asghar FA, Hilibrand AS. The impact of the Spine Patient Outcomes Research Trial (SPORT) results on orthopaedic practice. J Am Acad Orthop Surg. 2012; 20(3):160-166.
  2. Birkmeyer NJ, Weinstein JN, Tosteson AN, et al. Design of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2002; 27(12):1361-1372.
  3. Daffner SD, Hymanson HJ, Wang JC. Cost and use of conservative management of lumbar disc herniation before surgical discectomy. Spine J. 2010; 10(6):463-468.
  4. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. Four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009; 91(6):1295-1304.
  5. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med. 2007; 356(22):2257-2270.
  6. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs. nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA. 2006a; 296(20):2451-2459.
  7. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976). 2010; 35(14):1329-1338.
  8. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs. nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006b; 296(20):2441-2450.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Chou R, Loeser JD, Owens DK, et al.; American Pain Society Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976). 2009; 34(10):1066-1077.
  2. Kreiner DS, Shaffer WO, Summers J, et al. North American Spine Society (NASS). An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Revised 2013. Spine J. 2013; 13(7):734-743.
  3. North American Spine Society (NASS). NASS Coverage Policy Recommendations. Available at: www.spine.org. Accessed on June 26, 2017.
    • Lumbar Discectomy (2014a).
    • Lumbar Laminotomy (2014b).
  4. Washington State Department of Labor and Industries. Medical Treatment Guidelines. Criteria for entrapment of a single lumbar nerve root. Olympia, WA: Washington State Department of Labor and Industries; 1992. Available at: http: http://www.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/SingleLumbarNerveRoot.pdf. Accessed on May 30, 2018.
  5. Watters WC, Bono C, Gilbert T, et al. North American Spine Society (NASS). An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine J. 2009; 9(7):609-614.
Index

Lumbar discectomy
Lumbar hemilaminectomy
Lumbar laminectomy
Lumbar laminotomy

History

Status

Date

Action

Reviewed

07/26/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References and History sections of the document.

Reviewed

11/02/2017

MPTAC review. The document header wording was updated from “Current Effective Date” to “Publish Date.” Updated References and History sections of the document.

Reviewed

08/03/2017

MPTAC review. Updated Discussion/General Information, References and History sections of the document. Updated Coding section with 10/01/2017 ICD-10-CM changes.

Reviewed

08/04/2016

MPTAC review. Updated formatting in Clinical Indications sections. Updated Discussion/General Information, References and History sections of the document. Removed ICD-9 codes from Coding section.

Reviewed

08/06/2015

MPTAC review. Updated References and History sections of the document. Deleted Websites for Additional Information section.

Revised

08/14/2014

MPTAC review. In the medically necessary criteria, reformatted bullets #3 and #4. “Acute fracture causing symptomatic nerve root compression” added as a medically necessary indication. Coding, Discussion/General Information, References and History sections updated.

Revised

02/13/2014

MPTAC review. In the Clinical Indications section, the word “back” was removed from criterion #4a. Updated Discussion/General Information and References sections.

New

11/14/2013

MPTAC review. Initial document development.