Subject:
Epidural Spinal Endoscopy
Description:
_______________________________________________________________________________________
IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
__________________________________________________________________________________________________________________________
Epidural spinal endoscopy (also known as epiduroscopy, spinal endoscopy, myeloscopy, and epidural myeloscopy) is an endoscopic procedure where a miniature fiberoptic scope is inserted into the epidural space of the spinal cord. A steerable video guided catheter allows placement of a flexible fiberoptic scope. The proposed uses of this procedure include: (a) diagnostic - visualization of spinal nerve roots for areas of inflammation, adhesion, and/or scarring in patients with intractable radicular leg; and (b) therapeutic - injection of medication(s) directly into the area of inflammation or site of damage; performance of certain types of endoscopic surgery (e.g., lysis of adhesion, release of scar tissue around nerve roots, sectioning of nerve roots for treatment of spastic conditions, etc.). The procedure can be performed in an outpatient setting and takes about an hour.
Several flexible fiberscope endoscopes have been approved by the U.S. Food and Drug Administration (FDA) for the purpose of illumination and visualization of tissues of the epidural space in the lumbar and sacral spine to assist in the diagnosis of disease.
Policy:
[NOTE: For the mechanical break-up of epidural adhesions (epidural adhesiolysis), please refer to a separate policy on 'Lysis of Epidural Adhesions' (Policy #111) under the Treatment Section.
For Medicare Advantage, please refer to the Medicare Coverage Section below for coverage guidance.]
Epidural spinal endoscopy is considered investigational.
[RATIONALE : This policy was created in 2009 and has been updated regularly with literature searches through July 25, 2020. Two small studies (Hazer 23, Rapcan24) performed studies of the procedure. Hazer did a retrospective study of 88 patients which found that persons who had not had any surgical intervention prior to the epiduroscopy had the best results at the 1 year end date of the study, although all groups had a significant improvement in both Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) . The study concluded that epidurography helps improve the back and leg pain due to lumbar disc herniation in the early stage.
Rapcan, et al, performed a smaller (48 patients), randomized double-blinded parallel study on patients with Failed Back Surgery Syndrome (FBSS) assessing patient response to 2 different drugs used for the procedure, with a final result that there was no significant improvement in either group at the 1 year mark - both groups had a return to baseline on most pain scores on the ODI, with only continued improvement in one group on the NRS measure.
Current published evidence in the published, peer-reviewed medical literature is not sufficient to make any conclusions on its net effect on health outcomes. There is no evidence that this invasive technique provides clinically useful information not available with current noninvasive diagnostic methods.]
Medicare Coverage:
There is no National Coverage Determination (NCD) or Local Coverage Determination (LCD) for jurisdiction JL for this service. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy.
________________________________________________________________________________________
Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
___________________________________________________________________________________________________________________________
Index:
Epidural Spinal Endoscopy
Epidural Myeloscopy
Epiduroscopy
Myeloscopy
Spinal Endoscopy
References:
1. Saberski LR, Kitahata LM. Review of the clinical basis and protocol for epidural endoscopy. Conn Med. February 1996;60(2):71-73.
2. Saberski LR, Brull SJ. Spinal and epidural endoscopy: a historical review. Yale J Biol Med. January-April 1995;68(1-2):7-15.
3. Kambin P. Diagnostic and therapeutic spinal arthroscopy. Neurosurg Clin Am. 1996 Jan;7(1):65-76.
4. Kawauchi Y, Yone K, Sakou T. Myeloscopic observation of adhesive arachnoiditis in patients with lumbar spinal canal stenosis. Spinal Cord. 1996 Jul;34(7):403-410.
5. Regan JJ, Guyer RD. Endoscopic techniques in spinal surgery. Clin Orthop. 1997 Feb;335:122-139.
6. Alvarez JA, Cohen AR. Neonatal applications of neuroendoscopy. Neurosurg Clin N Am. 1998 Apr;9(2):405-413.
7. Teo C, Rahman S, Boop FA, et al. Complications of endoscopic neurosurgery. Childs Nerv Syst. 1996 May;12(5):248-253.
8. Devulder J, Bogaert L, Castille F, et al. Relevance of epidurography and epidural adhesiolysis in chronic failed back surgery patients. Clin J Pain. 1995 Jun;11(2):147-150.
9. Holmstrom, B Rawal N, Axelsson K, et al. Risk of catheter migration during combined spinal epidural block: percutaneous epiduroscopy study. Anesth Anlag. 1995 Apr;80(4):747-753.
10. Information from the FDA website http://www.fda.gov
11. Yeung AT. The evolution of percutaneous spinal endoscopy and discectomy: state of the art. Mt Sinai J Med 2000 Sep;67(4):327-332.
12. Richardson J, McGurgan P, Cheema S, et al. Spinal endoscopy in chronic low back pain with radiculopathy. A prospective case series. Anaesthesia 2001 May;56(5):454-460.
13. Tobita T, Okamoto M, Tomita M, et al. Diagnosis of spinal disease with ultrafine flexible fiberscopes in patients with chronic pain. Spine 2003 Sep;28(17):2006-12.
14. Ruetten S, Meyer O, Godolias G. Endoscopic surgery of the lumbar epidural space (epiduroscopy): results of therapeutic intervention in 93 patients. Minim Invasive Neurosurg 2003 Feb;46(1):1-4.
15. Kitahata LM. Recent advances in epiduroscopy. J Anesth. 2002;16(3):222-8.
16. National Institute for Clinical Excellence (NICE). Interventional Procedure Consultation Document: Endoscopic epidural procedures. February 2004.
17. ECRI Institute. Health Technology Assessment Information Service (HTAIS). Custom Hotline Response: Epidurolysis for Low Back Pain. Updated 10/09/2007 (current as of 03/19/08).
18. Helm S, Havek SM, Colson J, et al. Spinal endoscopic adhesiolysis in post lumbar surgery syndrome: an update of assessment of the evidence. Pain Physician. 2013 Apr;16(2 Suppl):SE125-50.
19. Van Boxem K(1), Cheng J, Patijn J, van Kleef M et al. Lumbosacral radicular pain. Pain Pract. 2010 Jul-Aug;10(4):339-58.
20. Kallewaard JW(1), Vanelderen P, Richardson J et al. Epiduroscopy for patients with lumbosacral radicular pain. Pain Pract. 2014 Apr;14(4):365-77.
21. Bosscher HA, Heavner JE. Lumbosacral epiduroscopy findings predict treatment outcome. Pain Pract 2014 Jul;14(6):506-14.
22. Jo DH. Epiduroscopy as a Diagnostic Tool for the Lower Back Pain and/or Leg Pain. Korean J Pain. 2016 Jul;29(3):151-2.
23. Hazer DB, Acarbas A, Rosberg H E. The outcome of epiduroscopy treatment in patients with chronic low back pain and radicular pain, operated or non-operated for lumbar disc herniation: a retrospective study in 88 patients. Korean J Pain. 2018 Apr;31(2):109-115.
24. Rapcan R, Kocan L, Mlaka J, et al. A Randomized, Multicenter, Double-Blind, Parallel Pilot Study Assessing the Effect of Mechanical Adhesiolysis vs Adhesiolysis with Corticosteroid and Hyaluronidase Administration into the Epidural Space During Epiduroscopy. Pain medicine (Malden, Mass.) 2018 doi: 10.1093/pm/pnx328 [published Online First: Epub Date]|.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
_________________________________________________________________________________________
Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
____________________________________________________________________________________________________________________________ |