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Discography

Section: Surgery
Effective Date: July 01, 2018
Revised Date: August 08, 2019
Last Reviewed: July 16, 2019

Description

Discography, also known as provocative discography, is an imaging-guided procedure in which a contrast agent is injected into the nucleus pulposus of the disc to evaluate intervertebral disc pathology.

Criteria

Discography of the lumbar vertebrae may be considered medically necessary for the evaluation of low back pain with or without lower extremity pain when ALL of the following are present:

  • Pain is unrelenting and has persisted for an extended period of time (may be least three (3) months); and
  • Pain has not responded to conservative treatment measures (i.e., NSAIDs, physical therapy, etc.); and
  • Non-invasive diagnostic studies have failed to provide sufficient diagnostic information regarding the origin of pain; and
  • There is no evidence of contraindications such as severe spinal stenosis resulting in intraspinal obstruction, infection, or predominantly psychogenic pain; and
  • At least ONE of the following indications must be present:
    • A high index of suspicion for discogenic pain and the pain is severe enough to consider surgical intervention; or
    • For failed back surgery individuals, to distinguish between painful pseudoarthrosis or a symptomatic disc in a posteriorly fused segment.

All other indications are considered not medically necessary.

Procedure Codes

62290
72295

Cervical and thoracic discography, are each considered experimental/investigational and therefore non-covered because the safety and and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

62291
72285

Diagnosis Codes

M43.00 M43.01 M43.02 M43.03 M43.04 M43.05 M43.06
M43.07 M43.08 M43.09 M43.10 M43.11 M43.12 M43.13
M43.14 M43.15 M43.16 M43.17 M43.18 M43.19 M46.46
M46.47 M47.16 M47.26 M47.27 M47.28 M47.816 M47.817
M47.818 M47.896 M47.897 M47.898 M48.061 M48.062 M48.07
M51.06 M51.14 M51.15 M51.17 M51.26 M51.27 M51.36
M51.37 M51.46 M51.47 M51.86 M51.87 M54.5 M54.14
M54.15 M54.16 M54.17 M54.30 M54.31 M54.32 M54.40
M54.41 M54.42 M96.1 M99.13 M99.23 M99.33 M99.43
M99.53 M99.63 M99.73 S33.0XXA S33.100A S33.101A S33.110A
S33.111A S33.120A S33.121A S33.130A S33.131A S33.140A S33.141A

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