28055
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
6.13
Facility
$371.75
Non-Facility
$371.75
Documentation Required
- Record of prior conservative treatments tried and failed (e.g., trials of oral antispasmodics such as baclofen, phenol injections, botulinum toxin injections, physical therapy, bracing) including dates and responses.
- Assessment documenting ambulatory potential and intrinsic lower extremity motor power (for SPR/SDR: documentation that impairment is due to spasticity rather than profound weakness), and patient/caregiver capacity and motivation to participate in post-operative rehabilitation.
- Age documentation when relevant (e.g., children aged 2–6 years are described as optimal candidates for SPR/SDR).
- Documentation of contraindications screened: presence/absence of dystonia, rigidity, severe basal ganglia damage, fixed joint deformities, progressive neurologic disorders, choreo-athetosis, cerebellar ataxia, or profound weakness.
Key Coverage Criteria
- SPR/SDR in children with CP when there is demonstrated limitation in ambulation primarily due to spasticity and not due to intrinsic muscle weakness.
- SPR/SDR for children who have tried and failed conservative medical management for spasticity (including oral baclofen or other muscle relaxants, phenol injections, physical therapy, bracing, orthopedic surgery) and who have capacity and motivation to participate in post-operative rehabilitation.
- SPR/SDR considered optimal for children aged approximately 2 to 6 years (children in this age range are described as optimal candidates).
- Selective tibial nerve neurotomy (selective neurotomy) as a surgical option to treat focal spastic equinovarus foot in adults (post-stroke / hemiplegic patients) — shown to reduce ankle stiffness and impairments associated with spastic equinovarus foot.
- Selective peripheral neurotomy / microsurgical selective peripheral neurotomy for treatment of focal spasticity (upper or lower limb) where focal surgical denervation is appropriate.
- Selective percutaneous myofascial lengthening (SPML) for release of tight myofascial/tendon bands (e.g., hip adductors, hamstrings, gastrocnemius/Achilles) in children with spastic CP when primary contracture interferes with walking, sitting, or causes joint subluxation.
1 Active Policy
AETNA-CPB-0362 — Spasticity Management
Related Codes
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