Treatment of Tarlov Cysts

This policy addresses radiologic evaluation and interventional/surgical treatment of Tarlov (perineural/sacral meningeal) cysts — including MRI/CT/CT-myelography and procedures such as cyst fenestration with fibrin glue, aspiration/drainage, cyst cavity reinforcement (fat, tissue adhesive, muscle flap), and laminectomy/decompression when indicated. Coverage is limited to symptomatic patients whose cyst size and location correlate with neurological signs (eg, radiculopathy, cauda equina, chronic sacral/coccygeal pain, bowel/bladder or sexual dysfunction) after failure of conservative therapy (typically 6–12 weeks) and only when all listed criteria are met; asymptomatic cysts are not treated, some reconstructive or other procedures are considered experimental/unproven, evidence is limited, and the policy is inactive for claims adjudication.

"Cyst fenestration with fibrin glue injection for Tarlov cysts (perineural cyst, sacral perineural cyst, sacral meningeal cyst) when the individual meets all specified clinical criteria."