22526
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
5.70
Facility
$289.25
Non-Facility
$1939.26
Documentation Required
- Member-specific benefit plan document must be referenced when deciding coverage; 'When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan.' (Instructions for Use)
- Informational (FDA PMA language): For Barricaid® (PMA), indication requires confirmation 'by history, physical examination and imaging studies which demonstrate neural compression using MRI' and that the device is used 'to treat a large annular defect (between 4-6 mm tall and between 6-10 mm wide) following a primary discectomy procedure at a single level between L4 and S1.' (U.S. Food and Drug Administration section)
- Applicable codes and coding lists are provided for reference only and do not establish coverage; documentation should support medical necessity per the member's benefit plan and any applicable federal/state mandates. (Applicable Codes / Instructions for Use)
Key Coverage Criteria
- None — this Medical Policy states the following procedures are unproven and not medically necessary due to insufficient evidence of efficacy: Annular closure devices (ACDs); Percutaneous injection of allogeneic cellular/tissue-based products; Thermal intradiscal procedures (TIPs) for treating discogenic pain. (Coverage Rationale)
- Note (informational, not a payer coverage determination): FDA premarket approval (PMA) for the Barricaid® Annular Closure Device is described in the document: 'indicated for reducing the incidence of reherniation and reoperation in skeletally mature patients with radiculopathy (with or without back pain) attributed to a posterior or posterolateral herniation, and confirmed by history, physical examination and imaging studies which demonstrate neural compression using MRI to treat a large annular [...]
- Disc inflammation reduction / attempts at intervertebral disc regeneration (preclinical biologic/growth factor approaches)
- Use of intradiscal biologic agents (PRP, mesenchymal stem cells, other biologics) for treatment of discogenic LBP (investigational/experimental context)
- None — Aetna considers thermal intradiscal procedures (TIPs) experimental and investigational for relief of discogenic pain or other indications because their effectiveness has not been established.
- Discogenic low back pain (LBP) confirmed by provocation discography or by clinical and imaging findings consistent with discogenic pain
12 Active Policies
AETNA-CPB-0602 — Intradiscal Procedures
UMR-POL-UMR-discogenic-pain-treatment — Discogenic Pain Treatment
SUREST-POL-SUREST-discogenic-pain-treatment — Discogenic Pain Treatment
CIGNA-0509 — Intraoperative Monitoring - (0509)
UHC-POL-discogenic-pain-treatment
Related Codes
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