Spasticity Management

Aetna considers neurosurgical procedures for refractory spasticity—including longitudinal myelotomy, DREZotomy, percutaneous radiofrequency/thermal rhizotomy, peripheral neurotomy, and selective posterior (dorsal) rhizotomy (optimal age 2–6)—medically necessary only when the member has good intrinsic lower‑extremity motor power but ambulation limited by spasticity, is able and motivated for postoperative rehabilitation, and has failed non‑surgical medical management (e.g., baclofen or other muscle relaxants). The policy excludes numerous listed treatments as experimental/investigational (e.g., acupuncture/electroacupuncture, extracorporeal shock wave, various electrical/magnetic stimulation therapies, chemodenervation with alcohol/phenol for SCI, spinal cord stimulation, tibial nerve neurotomy) and disallows many specific CPT/HCPCS codes, and it states selective posterior rhizotomy is contraindicated with concomitant dystonia/rigidity, profound lower‑extremity weakness, progressive neurologic disorders, severe basal ganglia damage, or severe fixed deformities/scoliosis.