Billing chart: Blues highlight medical, benefit policy changes

22858

Established procedures:
22856, 22861, 22864

Investigational:
0095T, 0098T, 0375T

Basic benefit and medical policy

Cervical artificial intervertebral discs

The safety and effectiveness of the insertion of cervical artificial intervertebral discs have been established. It’s a useful therapeutic option for patients meeting patient selection criteria. The policy has been updated, effective Jan. 1, 2017.

Payment policy

The code 22858 must be billed with a primary procedure code.

Inclusions:
The patient must meet all of the following:

• The device is approved by the U.S. Food and Drug Administration
• The patient’s is skeletally mature
• The patient has intractable cervical radicular pain or myelopathy
• Which has failed at least six weeks of conservative nonoperative treatment, including active pain management program or protocol, under the direction of a physician with pharmacotherapy that addresses neuropathic pain and other pain sources and physical therapy, or
• If the patient has severe or rapidly progressive symptoms of nerve root or spinal cord compression requiring hospitalization or immediate surgical treatment 
• Degeneration is documented by MRI, CT or myelography
• Cervical degenerative disc disease is from C3-C7
• The patient is free from contraindication to cervical artificial Intervertebral disc implantation

New:
Simultaneous cervical artificial intervertebral disc implantation at a second level may be considered established if the above criteria are met for each disc level, and the device is FDA-approved for two levels (i.e., Mobi-C, Prestige LP).

Subsequent cervical artificial intervertebral disc implantation at an adjacent level may be considered established when all of the following are met:

• Criteria 1-6 above are met.
• The device is FDA-approved for two levels.
• The planned subsequent procedure is at a different cervical level than the initial cervical artificial disc replacement.
• Clinical documentation that the initial cervical artificial intervertebral disc implantation is fully healed.

Exclusions:

• Disc implantation at more than  two levels 
• Combined use of an artificial cervical disc and fusion
• Prior surgery at the treated level
• Previous fusion at another cervical level
• Translational (segmental) instability
• Anatomical deformity (e.g., ankylosing spondylitis)
• Rheumatoid arthritis or other autoimmune disease
• Presence of facet arthritis
• Active infection
• Metabolic bone disease (e.g., osteoporosis, osteopenia, osteomalacia)
• Malignancy affecting the cervical spine

61885, 61886

Basic benefit and medical policy

Additional payable diagnosis codes

61885 and 61886 now have additional payable diagnosis codes of:

• G24.1 — Genetic torsion dystonia
• G24.2 — Idiopathic nonfamilial dystonia
• G24.3 — Spasmodic Torticollis
• G24.4 — Idiopathic orofacial dystonia
• G24.5 — Blepharospasm
• G24.9 — Dystonia, unspecified

61645, 61650, 61651
Experimental (effective Jan. 1, 2017):
61630

Basic benefit and medical policy

Intracranial stent placement

Intracranial stent placement is considered established as part of the endovascular treatment of intracranial aneurysms for patients when surgical treatment isn’t appropriate and standard endovascular techniques don’t allow for complete isolation of the aneurysm, e.g., wide-neck aneurysm (>4 mm) or sack-to-neck ratio less than 2:1.

Intracranial flow-diverting stents with FDA approval for the treatment of intracranial aneurysms may be considered established as part of the endovascular treatment of intracranial aneurysms that meet anatomic criteria and aren’t amenable to surgical treatment or standard endovascular therapy.

Intracranial stent placement is considered experimental in the treatment of intracranial aneurysms when selection criteria aren’t met.

Intracranial percutaneous transluminal angioplasty with or without stenting is considered experimental in the treatment of atherosclerotic cerebrovascular disease.

The use of endovascular mechanical embolectomy with a device with FDA approval for the treatment of acute ischemic stroke may be considered established as part of the treatment of acute ischemic stroke for patients who meet selection criteria.

Endovascular interventions are considered experimental for the treatment of acute ischemic stroke when selection criteria aren’t met.

Note: Criteria were published in the May 2016 edition of The Record and are available in the medical policy.

Payment policy

Procedure codes 61645, 61650 and 61651 have been added to the policy and will be payable retroactively to Jan. 1, 2016. Code 61630 won’t be covered effective Jan. 1, 2017.