Clinical UM Guideline
|Subject:||Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy|
|Guideline #:||CG-SURG-38||Current Effective Date:||10/06/2015|
|Status:||Reviewed||Last Review Date:||08/06/2015|
This document addresses laminectomy, hemi-laminectomy, laminotomy and discectomy as a means to surgically manage various lumbar conditions.
A lumbar laminectomy is a surgical procedure which involves the removal of a portion of the bony arch, or lamina, on the dorsal surface of a vertebra. The procedure is performed to relieve pressure on the nerve roots and spinal cord. The most common reason for performing a laminectomy is to treat spinal stenosis which is a chronic narrowing of the spinal canal due to degenerative arthritis and disc degeneration. If only one side is removed, it is called a hemilaminectomy. It is not uncommon for a laminectomy to be performed in combination with other surgical procedures such as discectomy (diskectomy), foraminotomy, spinal fusion or excision of an intraspinal tumor or lesion. In most cases a laminectomy is performed as an elective procedure rather than as emergency surgery.
For information regarding other spinal procedures, see:
Note: When procedure is performed using a percutaneous or endoscopic approach (as opposed to an open approach with direct visualization), refer to SURG.00071 Percutaneous and Endoscopic Spinal Surgery.
Lumbar laminectomy, hemilaminectomy, laminotomy (for unilateral symptoms), and/or discectomy is considered medically necessary when at least one of the following criteria is met:
Note: Conservative non-operative therapy consists of an appropriate combination of medication (for example, Non-Steroidal Anti-Inflammatory Drugs [NSAIDs], analgesics), physical therapy, spinal manipulation therapy, epidural steroid injections, or other interventions based on the individual's specific presentation, physical findings and imaging results.
Not Medically Necessary:
Lumbar laminectomy is considered not medically necessary when criteria above are not met and for all other indications not listed above as medically necessary.
Lumbar hemilaminectomy is considered not medically necessary when criteria above are not met and for all other indications not listed above as medically necessary.
Lumbar laminotomy is considered not medically necessary when criteria above are not met and for all other indications not listed above as medically necessary.
Lumbar discectomy is considered not medically necessary when criteria above are not met and for all other indications not listed above as medically necessary.
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|63005||Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis) 1 or 2 vertebral segments; lumbar, except for spondylolisthesis|
|63012||Laminectomy with removal of abnormal facets and/or pars interarticularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)|
|63017||Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar|
|63030||Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar|
|63035||Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar [when specified as lumbar]|
|63042||Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, re-exploration, single interspace; lumbar|
|63044||Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, re-exploration, single interspace; each additional lumbar interspace|
|63047||Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar|
|63048||Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar [when specified as lumbar]|
|63056||Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)|
|63057||Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar [when specified as lumbar]|
|63185||Laminectomy with rhizotomy; 1 or 2 segments [when specified as lumbar]|
|63190||Laminectomy with rhizotomy; more than 2 segments [when specified as lumbar]|
|63200||Laminectomy, with release of tethered spinal cord, lumbar|
|63252||Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar|
|63267||Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar|
|63272||Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar|
|63277||Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar|
|63282||Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar|
|63287||Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracolumbar|
|63290||Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural lesion, any level [when specified as lumbar]|
|ICD-10 Procedure||[For dates of service on or after 10/01/2015]|
|008Y0ZZ||Division of lumbar spinal cord, open approach|
|008Y4ZZ||Division of lumbar spinal cord, percutaneous endoscopic approach|
|009Y00Z||Drainage of lumbar spinal cord with drainage device, open approach|
|009Y0ZZ||Drainage of lumbar spinal cord, open approach|
|009Y40Z||Drainage of lumbar spinal cord with drainage device, percutaneous endoscopic approach|
|009Y4ZZ||Drainage of lumbar spinal cord, percutaneous endoscopic approach|
|00BY0ZZ||Excision of lumbar spinal cord, open approach|
|00BY4ZZ||Excision of lumbar spinal cord, percutaneous endoscopic approach|
|00NY0ZZ||Release lumbar spinal cord, open approach|
|00NY4ZZ||Release lumbar spinal cord, percutaneous endoscopic approach|
|018B0ZZ||Division of lumbar nerve, open approach|
|018B4ZZ||Division of lumbar nerve, percutaneous endoscopic approach|
|0SB00ZZ||Excision of lumbar vertebral joint, open approach|
|0SB04ZZ||Excision of lumbar vertebral joint, percutaneous endoscopic approach|
|0SB20ZZ||Excision of lumbar vertebral disc, open approach|
|0SB24ZZ||Excision of lumbar vertebral disc, percutaneous endoscopic approach|
|0SB30ZZ||Excision of lumbosacral joint, open approach|
|0SB34ZZ||Excision of lumbosacral joint, percutaneous endoscopic approach|
|0SB40ZZ||Excision of lumbosacral disc, open approach|
|0SB44ZZ||Excision of lumbosacral disc, percutaneous endoscopic approach|
|0SN00ZZ||Release lumbar vertebral joint, open approach|
|0SN04ZZ||Release lumbar vertebral joint, percutaneous endoscopic approach|
|0SN20ZZ||Release lumbar vertebral disc, open approach|
|0SN24ZZ||Release lumbar vertebral disc, percutaneous endoscopic approach|
|0SN30ZZ||Release lumbosacral joint, open approach|
|0SN34ZZ||Release lumbosacral joint, percutaneous endoscopic approach|
|0SN40ZZ||Release lumbosacral disc, open approach|
|0SN44ZZ||Release lumbosacral disc, percutaneous endoscopic approach|
|0ST20ZZ||Resection of lumbar vertebral disc, open approach|
|0ST40ZZ||Resection of lumbosacral disc, open approach|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
|C41.2||Malignant neoplasm of vertebral column|
|C70.1||Malignant neoplasm of spinal meninges|
|C72.0-C72.1||Malignant neoplasm of spinal cord, cauda equina|
|C79.49||Secondary malignant neoplasm of other parts of nervous system|
|D16.6||Benign neoplasm of vertebral column|
|D32.1||Benign neoplasm of spinal meninges|
|D33.4||Benign neoplasm of spinal cord|
|D42.1||Neoplasm of uncertain behavior of spinal meninges|
|D43.4||Neoplasm of uncertain behavior of spinal cord|
|G06.1||Intraspinal abscess and granuloma|
|G83.4||Cauda equina syndrome|
|K59.2||Neurogenic bowel, not elsewhere classified|
|M08.1||Juvenile ankylosing spondylitis|
|M43.06-M43.07||Spondylolysis, lumbar/lumbosacral regions|
|M43.16-M43.17||Spondylolisthesis, lumbar/lumbosacral regions|
|M45.6-M45.7||Ankylosing spondylitis, lumbar/lumbosacral regions|
|M47.16-M47.17||Other spondylosis with myelopathy, lumbar/lumbosacral regions|
|M47.26-M47.27||Other spondylosis with radiculopathy, lumbar/lumbosacral regions|
|M47.816-M47.817||Spondylosis without myelopathy or radiculopathy, lumbar/lumbosacral regions|
|M47.896-M47.897||Other spondylosis, lumbar/lumbosacral regions|
|M48.06-M48.07||Spinal stenosis, lumbar/lumbosacral regions|
|M48.36-M48.37||Traumatic spondylopathy, lumbar/lumbosacral regions|
|M48.8X6-M48.8X7||Other specified spondylopathies, lumbar/lumbosacral regions|
|M51.06-M51.07||Intervertebral disc disorders with myelopathy, lumbar/lumbosacral regions|
|M51.16-M51.17||Intervertebral disc disorders with radiculopathy, lumbar/lumbosacral regions|
|M51.26-M51.27||Other intervertebral disc displacement, lumbar/lumbosacral regions|
|M51.36-M51.37||Other intervertebral disc degeneration, lumbar/lumbosacral regions|
|M51.46-M51.47||Schmorl's nodes, lumbar/lumbosacral regions|
|M51.86-M51.87||Other intervertebral disc disorders, lumbar/lumbosacral regions|
|M54.16-M54.17||Radiculopathy, lumbar/lumbosacral regions|
|M54.40-M54.42||Lumbago with sciatica|
|M54.5||Low back pain|
|M96.1||Postlaminectomy syndrome, not elsewhere classified|
|Q27.39||Arteriovenous malformation, other site|
|S32.000A-S32.059S||Fracture of lumbar vertebra|
|S34.21XA-S34.21XS||Injury of nerve root of lumbar spine|
|ICD-9 Procedure||[For dates of service prior to 10/01/2015]|
|For the following procedures when specified as lumbar:|
|03.02||Reopening of laminectomy site|
|03.09||Other exploration and decompression of spinal canal|
|03.1||Division of intraspinal nerve root|
|03.4||Excision or destruction of lesion of spinal cord or spinal meninges|
|03.6||Lysis of adhesions of spinal cord and nerve roots|
|80.50||Excision or destruction of intervertebral disc, unspecified|
|80.51||Excision of intervertebral disc|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|170.2||Malignant neoplasm of vertebral column, excluding sacrum and coccyx|
|192.2||Malignant neoplasm of spinal cord (cauda equina)|
|198.3||Secondary malignant neoplasm of brain and spinal cord|
|213.2||Benign neoplasm of vertebral column, excluding sacrum and coccyx|
|225.3-225.4||Benign neoplasm of spinal cord (cauda equina), spinal meninges|
|237.5-237.6||Neoplasm of uncertain behavior of brain and spinal cord, meninges|
|343.0-343.9||Infantile cerebral palsy|
|344.60-344.61||Cauda equina syndrome|
|721.3||Lumbosacral spondylosis without myelopathy|
|721.42||Spondylosis with myelopathy, lumbar region|
|722.10||Displacement of lumbar intervertebral disc without myelopathy|
|722.32||Schmorl's nodes, lumbar region|
|722.52||Degeneration of lumbar or lumbosacral intervertebral disc|
|722.73||Intervertebral disc disorder with myelopathy, lumbar region|
|722.83||Postlaminectomy syndrome, lumbar region|
|722.93||Other and unspecified disc disorder, lumbar region|
|724.02-724.03||Spinal stenosis, lumbar region|
|724.4||Thoracic or lumbosacral neuritis or radiculitis, unspecified|
|742.9||Unspecified anomaly of brain, spinal cord, and nervous system [arteriovenous malformation]|
|756.11-756.12||Other congenital anomalies; spondylolysis, lumbosacral region, spondylolisthesis|
|805.4||Fracture of vertebral column without mention of spinal cord injury, lumbar, closed|
|805.5||Fracture of vertebral column without mention of spinal cord injury, lumbar, open|
|953.2||Injury to nerve roots and spinal plexus; lumbar root|
Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy
Lumbar laminectomy, hemilaminectomy, laminotomy and discectomy are established surgical options for several conditions when symptoms persist despite noninvasive treatment (when conservative management is appropriate) or as first line treatment for certain emergencies. Several specialty associations/societies have published guidelines which provide criteria for when lumbar laminectomy, hemilaminectomy, laminotomy and/or discectomy is considered an appropriate surgical intervention. There are also numerous peer-reviewed articles that discuss the pros and cons of these procedures.
As with all surgical procedures, lumbar surgery is not without risk. It has been reported that dural tears occur in approximately 10% of individuals undergoing laminectomy, and neurologic injuries may occur in about 2.5%. The American Pain Society (APS) guidelines on interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain recommended that clinicians discuss the risks and benefits of surgery as an "Option" (that is, strong recommendation, high-quality evidence). It is further recommended that shared decision-making regarding surgery include a specific discussion about moderate/average benefits, which appear to decrease over time in affected individuals who undergo surgery (Chou, 2009).
The North American Spine Society (NASS) "Coverage Policy Recommendations" provide clinical indications for several spine procedures including, but not limited to lumbar laminotomy and lumbar discectomy. According to information on the NASS website, the Coverage Policy Recommendations were created using "an evidence-based approach to spinal care when possible. In the absence of strict evidence-based criteria, policies reflect the multidisciplinary and non-conflicted experience and expertise of the authors in order to reflect reasonable standard practice indications in the United States" The authors also state that the coverage recommendations are not representative of a "standard of care" and should not be viewed as "fixed treatment protocols" (NASS, 2014).
Low back pain
The National Institute for Clinical Excellence's (NICE) guidance on early management of people with non-specific low back pain (LBP) indicates that it is important for practitioners to assist individuals with persistent non-specific LBP self-manage their condition. The guidance recommends that one of the following treatment options be offered to individuals with LBP: (1) An exercise program; (2) A course of manual therapy (i.e., spinal manipulation, spinal mobilization, massage); (3) A course of acupuncture, and pharmacological therapy; or (4) Referral to a combined physical and psychological treatment program may be appropriate for individuals who have received at least one less intensive treatment and have high disability and/or significant psychological distress. With regards to invasive procedures, the authors caution that:
Robust trials, including health economic evaluations, should be carried out to determine the effectiveness and cost effectiveness of invasive procedures – in particular, facet joint injections and radiofrequency lesioning. These should include the development of specific criteria for patient selection and a comparison with non-invasive therapies (2009).
The APS recommends that in instances where conservative management fails to relieve symptoms of radiculopathy and there is strong evidence of dysfunction of a specific nerve root confirmed at the corresponding level by CT or MRI, further evaluation and more invasive treatment, including spine surgery, may be proposed as a treatment option (Chou, 2009).
According to the Washington State Department of Labor and Industries guidelines which provide criteria for single lumbar nerve root entrapment, lumbar laminectomy is appropriate for individuals who failed to respond to treatment after a minimum of four weeks of conservative therapy and have both objective and subjective findings of lumbar nerve root entrapment (Washington State, 1999).
Lumbar disc (herniated intervertebral disc)
Most instances of lumbar disc herniations will respond positively to conservative management and will not require surgical treatment. However, some individuals may have severe, unremitting pain that requires more immediate intervention.
The Spine Patient Outcomes Research Trial (SPORT) was funded by the National Institutes of Health (NIH) to study the outcomes from surgical and nonsurgical management of three conditions: intervertebral disc herniation, degenerative spondylolisthesis, and lumbar spinal stenosis. Both surgical and nonsurgical care of intervertebral disc herniation resulted in significant improvement in symptoms of low back and leg pain. However, the treatment effect of surgery for intervertebral disc herniation was less than that seen in individuals with degenerative spondylolisthesis and lumbar spinal stenosis. The preliminary four-year outcomes data demonstrated more significant degrees of improvement in pain levels and function with surgical versus nonsurgical treatment in the chronic conditions of lumbar spinal stenosis and lumbar spinal stenosis with spondylolisthesis (Asghar, 2012; Weinstein, 2006a; Weinstein, 2006b; Weinstein, 2007; Weinstein, 2009).
According to the APS, decompressive laminectomy may be an acceptable option for individuals experiencing disabling and persistent leg pain due to spinal stenosis, either with or without degenerative spondylolisthesis. The APS reports that decompressive laminectomy is associated with moderate benefits compared to nonsurgical therapy through 1 to 2 years, though the effects of the procedure appear to diminish with long-term follow-up. Although individuals on average do not worsen without surgery, improvements are less than those observed in individuals with radiculopathy due to herniated lumbar disc. Their guidelines indicate there is insufficient evidence to determine if laminectomy with fusion is more effective than laminectomy without fusion. The authors recommended that shared decision-making regarding surgery include a specific discussion about moderate/average benefits, which appear to decrease over time in affected individuals who undergo surgery (Chou, 2009).
Lumbar spinal stenosis and/or foraminal stenosis
NASS (2011) published evidence-based guidelines on the diagnosis and treatment of degenerative lumbar spinal stenosis. The NASS found that in the absence of evidence for or against any specific treatment, it is the work group's recommendation that medical/interventional treatment be considered for individuals with mild symptoms of lumbar spinal stenosis. The group also issued a consensus statement indicating that individuals with mild symptoms are generally not considered surgical candidates (Kreiner, 2011).
As mentioned above, the SPORT trial explored the outcomes from surgical and nonsurgical management of intervertebral disc herniation, degenerative spondylolisthesis, and lumbar spinal stenosis. The preliminary four-year outcomes data demonstrated more significant degrees of improvement in pain levels and function with surgical versus nonsurgical treatment in the chronic conditions of lumbar spinal stenosis and lumbar spinal stenosis with spondylolisthesis (Asghar, 2012; Weinstein, 2006a; Weinstein, 2006b; Weinstein, 2007; Weinstein, 2009; Weinstein, 2010).
According to NASS evidence-based guidelines on the diagnosis and treatment of degenerative lumbar spondylolisthesis, the purpose of the guidelines is to address key clinical questions surrounding the diagnosis and treatment of degenerative lumbar spondylolisthesis. The group assigned a "B" rating to the consensus statement that surgery be recommended for individuals with symptomatic spinal stenosis associated with low grade degenerative spondylolisthesis whose symptoms have been recalcitrant to a trial of medical/interventional treatment. The group also issued a statement that there is insufficient evidence to support the use of direct or indirect surgical decompression for the treatment of individuals with symptomatic spinal stenosis associated with low grade degenerative lumbar spondylolisthesis whose symptoms have been recalcitrant to a trial of medical/interventional treatment (Watters, 2008).
According to the SPORT trial investigation (see above), the outcomes data demonstrated more significant degrees of improvement in pain levels and function with surgical versus nonsurgical treatment in the chronic conditions of lumbar spinal stenosis and lumbar spinal stenosis with spondylolisthesis (Asghar, 2012; Weinstein, 2006a; Weinstein, 2006b; Weinstein, 2007; Weinstein, 2009; Weinstein, 2010).
Cauda equina (horse's tail) syndrome: A condition which results from the compression of multiple dorsal and ventral nerve roots in the lumbar spinal canal, usually as a result of a large central herniated disc.
Discectomy: The partial or complete removal of an intervertebral disc.
Hemilaminectomy: A surgical procedure in which the lamina is removed on one side of the vertebrae.
Herniated disc: A condition in which a portion of the nucleus pulposus extends through the annulus (the outer disc layers). Herniated discs may additionally be classified as: contained (there is still a retained thin outer layer of annulus or ligament), extruded (the nuclear material extends into the spinal canal) or sequestrated (when a herniated fragment migrates away from the disc).
Lamina: The part of the vertebra that forms the roof of the spinal canal.
Laminectomy: A spine operation to remove all or a portion of the roof of the spinal canal; frequently performed to decompress the neural elements.
Laminotomy: A spine operation in which the lamina is partially removed.
Radiculopathy: Any disease of the spinal nerve roots and spinal nerves; radiculopathy is characterized by pain which seems to radiate from the spine to extend outward to cause symptoms away from the source of the spinal nerve root irritation; causes of radiculopathy include deformities of the discs between the building blocks of the spine (the vertebrae).
Spine anatomy: The spine is divided into three major sections: the cervical (neck), the thoracic (mid-back) and lumbar spine (lower back). These sections are made up of individual bones called vertebrae, which are the primary weight bearing structures of the torso alternating with intervertebral discs.
Spinal stenosis: A chronic narrowing of the spinal canal due to degenerative arthritis and disc degeneration.
Spondylolisthesis: Forward slippage of one vertebral body with impingement upon the adjacent inferior disc.
Vertebrae: Bones that make up the spinal column which surround and protect the spinal cord.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Reviewed||08/06/2015||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References and History sections of the document. Deleted Websites for Additional Information section.|
|Revised||08/14/2014||MPTAC review. In the medically necessary criteria, reformatted bullets #3 and #4. "Acute fracture causing symptomatic nerve root compression" added as a medically necessary indication. Coding, Discussion/General Information, References and History sections updated.|
|Revised||02/13/2014||MPTAC review. In the Clinical Indications section, the word "back" was removed from criterion #4a. Updated Discussion/General Information and References sections.|
|New||11/14/2013||MPTAC review. Initial document development.|