Criteria
Cervical laminectomy may be considered medically necessary when ALL of the following conditions are met:
- Spinal cord or nerve root compression due to one of the following conditions:
- Spinal stenosis (with or without spondylolisthesis)
- Ossification of the posterior longitudinal ligament or the yellow ligament; or hypertrophy of the ligamentumflavum.
- Signs and/or symptoms that meet at least one of the following criteria:
- Neurologic deficits that are rapidly progressive; or
- Symptoms of cervical myelopathy (see Policy Guidelines section) or cervical cord compression (with or without radiculopathy); or
- Persistent debilitating pain that is refractory to at least six (6) weeks of conservative nonsurgical therapy (See Policy Guidelines section).
- Imaging studies (preferably magnetic resonance imaging) with findings of spinal cord compression, nerve root compression, and/ormyelographic changes, at a level corresponding to the indivdual's signs and symptoms.
Lumbar laminectomy may be considered medically necessary when ALL of the following conditions are met:
- Spinal cord or nerve root compression due to spinal stenosis (with or without spondylolisthesis);
- Signs and/or symptoms that meet at least one of the following criteria:
- Neurologic deficits that are rapidly progressive; or
- Neurologic claudication that is persistent and refractory to at least six (6) weeks of conservative nonsurgical therapy (see Policy Guidelines section); or
- Persistent debilitating pain that is refractory to at least six (6) weeks of conservative nonsurgical management (see Policy Guidelines section).
- Imaging studies (preferably magnetic resonance imaging) with findings of spinal cord or nerve root compression, at a level corresponding to the individual's signs and symptoms.
Laminectomy (cervical, thoracic, lumbar) may be considered medically necessary for space-occupying lesions of the spinal cord and/or spinal canal.
- Primary or metastatic tumors
- Abscesses or other localized infections.
Laminectomy (cervical or lumbar) is not medically necessary for spinal stenosis when the above criteria are not met.
Laminectomy is considered investigational for all other indications.
Policy Guidelines
Cervical Myelopathy And/Or Cord Compression
Signs and symptoms of cervical myelopathy and/or cord compression include the following (Epstein, 2003):
- Difficulty with fine movements of the hand and upper extremity
- Incoordination of the hand and upper extremity
- Atrophy of the thenar and hypothenar eminence
- Diffuse hyperreflexia and bilateral Babinski responses
- Decreased sensation, vibratory sense, and proprioception at a level of C5 or below
- Inability to perform tandem walk
- Bowel and bladder incontinence.
Conservative nonsurgical therapy for the duration specified should include the following:
- Use of prescription strength analgesics for several weeks at a dose sufficient to induce a therapeutic response
- Analgesics should include anti-inflammatory medications with or without adjunctive medications such as nerve membrane stabilizers or muscle relaxants; and
- Participation in at least six (6) weeks of physical therapy (including active exercise) or documentation of why the individual could not tolerate physical therapy; and
- Evaluation and appropriate management of associated cognitive, behavioral, or addiction issues
- Documentation of individual compliance with the preceding criteria.
Persistent debilitating pain is defined as:
- Significant level of pain on a daily basis as measured as a visual analog scale score of four (4) or greater; and
- Pain on a daily basis that has a documented impact on activities of daily living despite optimal conservative nonsurgical therapy as outlined above and appropriate for the individual.
Laminectomy may occasionally be performed for the sole indication of radiculopathy due to herniated disc. In these cases, discectomy alone is not sufficient to relieve compression on vital structures, and laminectomy is required for adequate decompression. Compression of the spine due to herniated disc is uncommon, and there are no standardized preoperative criteria to determine which individuals may require laminectomy in addition to discectomy.
The following procedures can be considered alternatives to laminectomy for decompression of the spinal cord. The specific indications for these alternative procedures are not standardized, and the evidence is insufficient to determine the effectiveness of these procedures compared with laminectomy.
- Hemilaminectomy
- Laminotomy
- Foraminotomy.
Medical necessity is established by documentation of medical history, physical findings, and diagnostic imaging results that demonstrate spinal nerve compression and support the surgical intervention. Documentation in the medical record must clearly support the medical necessity of the surgery and include medical history, physical examination, and diagnostic testing.
Medical History
- Assessment of comorbid physical and psychological health conditions (e.g. morbid obesity, current smoking, diabetes, renal disease, osteoporosis, severe physical deconditioning)
- History of back surgery, including minimally invasive back procedures
- Prior trial, failure, or contraindication to conservative medical/nonoperative interventions that may include but are not limited to the following:
- Activity modification for at least six (6) weeks
- Oral analgesics and/or anti-inflammatory medications
- Physical therapy
- Chiropractic manipulation
- oEpidural steroid injections.
Physical Examination
- Clinical findings including the individual's stated symptoms and duration.
Diagnostic Testing
- Radiologist's report of a magnetic resonance image or computerized tomography scan with myelogram of the spine within the past six (6) months showing a spine abnormality
- Report of the selective nerve root injection results, if applicable to the individual's diagnostic workup.
Procedure Codes
| 63001 |
63005 |
63015 |
63017 |
63052 |
63053 |
63270 |
| 63272 |
63275 |
63277 |
63280 |
63282 |
63285 |
63287 |
