DESCRIPTION
Percutaneous lumbar discectomy (PLD) is a surgical procedure performed for the resection of herniated lumbar disc material. PLD can be performed either manually or with an automated device. The manual procedure uses cutting forceps to remove nuclear material from within the disc annulus. The automated PLD uses a specially designed probe to excise small pieces of the nucleus, which are removed by aspiration. Both manual and automated PLD can be performed on an outpatient basis.
POLICY
Percutaneous lumbar discectomy for the treatment of a single lumbar disc is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Percutaneous lumbar discectomy for the treatment of disease/conditions other than an uncomplicated anulus is considered not medically necessary.
MEDICAL APPROPRIATENESS
Percutaneous lumbar discectomy for the treatment of a single lumbar disc is considered medically appropriate if the individual meets ALL of the following criteria:
There is an uncomplicated herniation that is contained within the anulus
There is a major complaint of acute unilateral leg pain localized to a single dermatome (i.e., radicular pain) or a major complaint of acute and intractable discogenic back pain consistent with a non-sequestered disc herniation
There are neurologic signs or symptoms (e.g., sensory abnormalities, reflex alterations, positive straight-leg raising test, weakness) that are consistent with a non-sequestered disc herniation
There is magnetic resonance imaging, computed tomography or myelography demonstrating a single herniation that is contained within the anulus of a lumbar disc (L1-L2 through L5-S1) and consistent with the signs and symptoms
There is a well-managed course of conservative therapy that has failed to relieve pain and other signs and symptoms, therefore, making the individual a candidate for invasive treatment
ABSENCE of ALL of the following:
History of previous chemonucleolysis or surgical treatment of the disc presently suspected to harbor a symptomatic herniation
Progressive neurologic dysfunction
Impairment of bowel or bladder function
Evidence of a sequestered disc or free fragment of disc
Evidence of vertebral disease, such as spinal stenosis or spondylolisthesis
SOURCES
Amoretti, N., David, P., Grimaud, A., Flory, P., Hovorka, I.,Roux, C., et al. (2006). Clinical follow-up of 50 patients treated by percutaneous lumbar discectomy. Clinical Imaging, 30 (4), 242-244. Abstract retrieved October 19, 2006 from PubMed database.
BlueCross BlueShield Association. Medical Policy Reference Manual. (5:2007). Percutaneous discectomy (7.01.18). Retrieved August 20, 2008 from BlueWeb.
Gibson JNA, Grant IC, Waddell G. Surgery for lumbar disc prolapse. The Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.:CD001350. DOI: 10.1002/14651858.CD001350.
Mariconda, M., Galasso, O., Secondulfo, V., Rotonda, G. D., & Milano, C. (2006). Minimum 25-year outcome and functional assessment of lumbar discectomy. Spine, 31 (22), 2593-2599. Abstract retrieved October 26, 2006 from PubMed database.
Maroon, J.C. (2002). Current concepts in minimally invasive discectomy. Neurosurgery, 51 (5 Suppl.), 137-145. Abstract retrieved June 5, 2003 from PubMed database.
Ramberg, N., & Sahlstrand, T. (2001). Early course and long-term follow-up after automated percutaneous lumbar discectomy. Journal of Spinal Disorders, 14 (6), 511-516. Abstract retrieved June 5, 2003 from PubMed database.
ORIGINAL EFFECTIVE DATE: 11/1987
MOST RECENT REVIEW DATE: 10/9/2008
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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