Nucleoplasty and Biacuplasty

Policy ID: S-159-020

Section: Surgery

Effective Date: July 01, 2018

Revised Date: January 22, 2020

Last Reviewed: July 21, 2022

Applies To: Commercial and Medicaid Expansion

Description

Nucleoplastyis a minimally invasive percutaneous procedure performed under local anesthesia that was developed as an alternative to open discectomy for treatment of chronic back pain related to disc herniation.Nucleoplasty may also be referred to as decompression nucleoplasty or plasma disc decompression.

Biacuplasty is a minimally invasive percutaneous procedure performed under local anesthesia for the treatment of chronic discogenic pain originating from annular fissures or contained disc herniation.

Criteria

Nucleoplasty

Nucleoplasty is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available peer-reviewed literature.

Procedure Codes

S2348

Biacuplasty

Biacuplasty is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available peer-reviewed literature.

Procedure Codes

64999

Diagnosis Codes

Not Applicable for this policy

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 annual review

Internal Medical Policy Committee 7-22-2020 No change in criteria

Internal Medical Policy Committee 7-22-2021 Annual Review - No changes in criteria

Internal Medical Policy Committee 7-21-2022 Annual Review - No changes in criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Section: Surgery

Effective Date: July 01, 2018

Last Reviewed: January 22, 2020

Archived Date: August 07, 2020

Applies To: Commercial Only

Description

Criteria

Nucleoplasty

Nucleoplasty is considered experimental/investigational and therefore non-covered as there are no long- term studies to support or prove the safety and efficacy of this procedure.

Procedure Codes

S2348

Biacuplasty

Biacuplasty is considered experimental/investigational and therefore non-covered as published data are inadequate to permit scientific conclusions regarding the safety and efficacy of this procedure.

Procedure Codes

64999

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