Subject:
Discography
Description:
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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.
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CMM-401: Discography
| CMM-401.1: Definitions |
| CMM-401.2: General Guidelines |
| CMM-401.3: Indications |
| CMM-401.4: Non-Indications |
| CMM-401.5: Procedure (CPT®) Codes |
CMM-401.1: Definitions
Discography is a diagnostic procedure in which a contrast material (dye) is injected into the nucleus pulposus of a disc. It has been used to justify the need for surgical intervention to treat back or neck pain. The general intent is to determine whether the disc is the source of pain (i.e., a diagnosis of discogenic pain) in patients with predominantly axial back or neck pain. Discography is presumed to yield two results:
® Pain provocation (provocative discography) - whether the patient's typical pain was reproduced by the injection of the contrast material (dye)
® Morphology - whether the contrast material (dye) images an abnormal pattern of the disc (e.g., annular tears, disc herniation) often based on a computed tomography (CT) scan.
Red flags indicate comorbidities that require urgent/emergent diagnostic imaging and/or referral for definitive therapy.
Behavioral yellow flags are defined as an active or history of substance abuse, depression, dissatisfaction with work, job disability, or anxiety diagnosis.
Clinically meaningful improvement is a global assessment showing at least 50% improvement, or pain relief is defined as a two (2) point drop in VAS pain scale where 10 is the worst pain imaginable and 0 is no pain at all.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
CMM-401.2: General Guidelines
Any of the following are considered to be red flags and the request for discography should go to medical review:
® Suspected unstable fractures of the spine which may be evidenced by a history of a recent fall or injury, and major motor weakness of a limb, or progressive neurological deficits, or bladder or bowel dysfunction.
® History of cancer with suspicion of metastatic spread which may be evidenced by major motor weakness of a limb, or pain which increases at night or at rest, or progressive neurological deficits, or bladder or bowel dysfunction, or unexplained weight loss of more than 10 pounds in 6 weeks.
® Infection with suspicion of an epidural abscess/discitis which may be evidenced by progressive neurological deficits, or fever of 100.4 for more than 48 hours, and C- reactive protein >10 mg/L, or recent (within 2 weeks) interventional spine procedures, or ESR >20 mm/hr, or immunocompromised (either immunodeficiency from any cause or IV drug abuse).
® Cauda equina syndrome which may be evidenced by bladder or bowel dysfunction, or saddle anesthesia, or progressive neurological deficits.
A post-discography CT scan is automatically approved as an add-on.
CMM-401.3: Indications
A diagnostic discography is considered medically necessary when it is an authorized benefit coverage for a planned discography.
Discography as a provocative diagnostic test for axial pain is considered medically necessary when all of the following are met:
† Absence of red flag condition
† Less than clinically meaningful improvement for at least 6 weeks which includes both of the following:
® NSAIDS and/or muscle relaxants
® Conservative self-care (muscle stretching, over the counter medications, regular exercise) or prescribed physical therapy core strengthening program
† Pain pattern and/or physical examination suggesting disc disease as evidenced by all of the following:
® Subacute axial pain > 12 weeks
® Axial pain worsening with upright posture
® Absence of signs and symptoms of radicular pain
® Absence of trigger points in affected area
® Absence of signs and symptoms of sacroiliac joint dysfunction
† Facet joint disease has been evaluated and ruled out
† Imaging suggestive of disc damage as evidenced by any of the following:
® Annular tears
® Contained disc herniation
® High intensity zones
† Absence of centralized pain syndromes, fibromyalgia, multicentric pain syndromes
† Evidence of both of the following for patients with chronic pain where there has been continuous opiate usage for 3 months or longer:
® Co-management of behavioral health and medical conditions
® A plan to address potential opiate overuse or abuse
† Coordination with a physician who may perform the succeeding covered therapeutic procedure.
CMM-401.4: Non-Indications
† The performance of a discography procedure in the presence of any red flag condition (see CMM-401.2: General Guidelines) is not considered medically necessary.
† The performance of functional anesthetic discography is considered investigational.
† Chemonucleolysis is considered inclusive with a discography procedure and is not considered medically necessary as a separate procedure.
† A diagnostic discography is not considered medically necessary for either of the following:
® Not coincident with a surgical procedure that includes a discectomy
® Not performed by both the surgeon and a supervising radiologist.
CMM-401.5: Procedure (CPT®) Codes
| This guideline relates to the CPT® code set below. Codes are displayed for informational purposes only. Any given code’s inclusion on this list does not necessarily indicate prior authorization is required. Pre- authorization requirements vary by individual payor. |
| CPT® | Code Description/Definition |
62290 | Injection Procedure for Discography Each Level; Lumbar |
62291 | Injection Procedure for Discography Each Level; Cervical or
Thoracic |
72285 | Discography, cervical or thoracic, radiological supervision and interpretation |
72295 | Discography, lumbar, radiological supervision and interpretation |
| This list may not be all inclusive and is not intended to be used for coding/billing purposes. The final determination of reimbursement for services is the decision of the individual payor (health insurance company, etc.) and is based on the member/patient/client/beneficiary’s policy or benefit entitlement structure as well as any third party payor guidelines and/or claims processing rules. Providers are strongly urged to contact each payor for individual requirements if they have not already done so. |
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.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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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.
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Index:
Discography
Provocative Discography
Diskography
Discogram
Functional Anesthetic Discography
References:
1. (ICSI) Institute for Clinical Systems Improvement. Health Care Guideline: Adult Acute and Subacute Low Back Pain15 ed. Bloomington (MN): Institute for Clinical Systems Improvement; January 2012.
2. Chou R., Qaseem, A., Snow, V., et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. Oct 2 2007;147(7):478-491.
3. Haig A. J., Colwell, M. Back Pain ACP Press; 2005.
4. Rigamonti D., Liem, L., Sampath, P., et al. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol. Aug 1999;52(2):189-196; discussion 197.
5. Boswell M. V., Trescot, A. M., Datta, S., et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. pain Physician. Jan 2007;10(1):7-111.
6. Boswell M. V., Shah, R. V., Everett, C. R., et al. Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines. pain Physician. Jan 2005;8(1):1-47.
7. Buenaventura R. M., Shah, R. V., Patel, V., et al. Systematic review of discography as a diagnostic test for spinal pain: an update. Pain. Physician. Jan 2007;10(1):147-164.
8. Carragee E. J., Alamin, T. F., Carragee, J. M. Low-pressure positive Discography in subjects asymptomatic of significant low back pain illness. Spine (Phila Pa 1976). Mar 1 2006;31(5):505-509.
9. Cohen S. P., Larkin, T. M., Barna, S. A., et al. Lumbar discography: a comprehensive review of outcome studies, diagnostic accuracy, and principles. Reg Anesth Pain Med. Mar-Apr 2005;30(2):163-183.
10. Endresen G. K. Fibromyalgia: a rheumatologic diagnosis? Rheumatol Int. Sep 2007;27(11):999-1004.
11. Ewing J. A. Detecting alcoholism. The CAGE questionnaire. JAMA. Oct 12 1984;252(14):1905-1907.
12. Wolfe F., Smythe, H. , Yunus, M. , et al. Guideline for the Diagnosis of Fibromyalgia Arthritis and Rheumatism. The American College of Rheumatology Arthritis & Rheumatism. 1990;33(2):160-172.
13. Dubois M. Y., Livovich, J., Fletwood, J., et al. Incompetence, drug diversion or pain management? Trying to draw the line. Pain Med. Mar 2002;3(1):73-77.
14. Fishbain D. A., Cutler, R. B., Rosomoff, H. L., et al. Is there a relationship between nonorganic physical findings (Waddell signs) and secondary gain/malingering? Clin J Pain. Nov-Dec 2004;20(6):399-408.
15. Giordano J., Schatman, M. E. A crisis in chronic pain care: an ethical analysis. Part three: Toward an integrative, multi-disciplinary pain medicine built around the needs of the patient. pain Physician. Nov-Dec 2008;11(6):775-784.
16. Kahan M., Srivastava, A., Wilson, L., et al. Misuse of and dependence on opioids: study of chronic pain patients. Can Fam Physician. Sep 2006;52(9):1081-1087.
17. Tacci J. A., Webster, B. S., Hashemi, L., et al. Healthcare utilization and referral patterns in the initial management of new-onset, uncomplicated, low back workers' compensation disability claims. J Occup Environ Med. Nov 1998;40(11):958-963.
18. Wasan A. D., Jamison, R. N., Pham, L., et al. Psychopathology predicts the outcome of medial branch blocks with corticosteroid for chronic axial low back or cervical pain: a prospective cohort study. BMC Musculoskelet Disord. 2009;10:22.
19. McCutcheon M. E., Thompson, W. C., 3rd. CT scanning of lumbar discography. A useful diagnostic adjunct. Spine (Phila Pa 1976). Apr 1986;11(3):257-259.
20. Pauza K.J. Educational Guidelines for the Performance of Spinal Injection Procedures. PASSOR (Physiatric Association of Spine, Sports and Occupational Rehabilitation of the American Academy of Physical Medicine and Rehabilitation. June 2001; Updated April 2004.
21. Willems P. C., Elmans, L., Anderson, P. G., et al. Provocative discography and lumbar fusion: is preoperative assessment of adjacent discs useful? Spine (Phila Pa 1976). May 1 2007;32(10):1094-1099; discussion 1100.
22. Madigan L., Vaccaro, A. R., Spector, L. R., et al. Management of symptomatic lumbar degenerative disk disease. J Am Acad Orthop Surg. Feb 2009;17(2):102-111.
23. Kang C. H., Kim, Y. H., Lee, S. H., et al. Can magnetic resonance imaging accurately predict concordant pain provocation during provocative disc injection? Skeletal Radiol. Sep 2009;38(9):877-885.
24. Nordin M., Carragee, E. J., Hogg-Johnson, S., et al. Assessment of Neck Pain and Its Associated Disorders: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976) 2008;33(4 Suppl):S101-122.
25. Kloth D. S., Fenton, D. S., Andersson, G. B., et al. Intradiscal electrothermal therapy (IDET) for the treatment of discogenic low back pain: patient selection and indications for use. pain Physician. Sep-Oct 2008;11(5):659-668.
26. (ODG) Official Disability Guidelines. Discography, IDET, Percutaneous Disk Surgery. October 24, 2012.
27. Chou R., Atlas, S. J., Stanos, S. P., et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). May 1 2009;34(10):1078-1093.
28. Freeman B. J., Mehdian, R. Intradiscal electrothermal therapy, percutaneous discectomy, and nucleoplasty: what is the current evidence? Curr Pain Headache Rep. Jan 2008;12(1):14-21.
29. Rathmell J. P., Saal, J.S. Discography, IDET, Percutaneous Discectomy, and Nucleoplasty: Complications and Their Preventions. Pain Medicine. 2008;9(Issue S1):S79-S81.
30. Derby R., Lee, S. H., Kim, B. J., et al. Pressure-controlled lumbar discography in volunteers without low back symptoms. Pain Med. May- Jun 2005;6(3):213-221; discussion 222-214.
31. Institute for Clinical Systems Improvement Guidelines for Low back Pain Institute for Clinical Systems Improvement (ICSI). 2008;13th Edition.
32. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. Oct 2 2007;147(7):478-491.
33. Haig AJ, Colwell MO. Back Pain ACP Press. 2005.
34. Rigamonti D, Liem L, Sampath P, et al. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol. Aug 1999;52(2):189-196; discussion 197.
35. Boswell MV, Trescot AM, Datta S, et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. Jan 2007;10(1):7-111.
36. Buenaventura RM, Shah RV, Patel V, et al. Systematic review of discography as a diagnostic test for spinal pain: an update. Pain Physician. Jan 2007;10(1):147-164.
37. Cohen SP, Larkin TM, Barna SA, et al. Lumbar discography: a comprehensive review of outcome studies, diagnostic accuracy, and principles. Reg Anesth Pain Med. Mar-Apr 2005;30(2):163-183.
38. Endresen GK. Fibromyalgia: a rheumatologic diagnosis? Rheumatol Int. Sep 2007;27(11):999-1004.
39. Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA. Oct 12 1984;252(14):1905-1907.
40. The American College of Rheumatology. Guideline for Diagnosis of Fibromyalgia Arthritis and Rheumatism. February 1990;33(2).
41. Dubois MY, Livovich J, Fletwood J, et al. Incompetence, drug diversion or pain management? Trying to draw the line. Pain Med. Mar 2002;3(1):73-77.
42. Fishbain DA, Cutler RB, Rosomoff HL, et al. Is there a relationship between nonorganic physical findings (Waddell signs) and secondary gain/malingering? Clin J Pain. Nov-Dec 2004;20(6):399-408.
43. Giordano J, Schatman ME. A crisis in chronic pain care: an ethical analysis. Part three: Toward an integrative, multi-disciplinary pain medicine built around the needs of the patient. Pain Physician. Nov-Dec 2008;11(6):775-784.
44. Kahan M, Srivastava A, Wilson L, et al. Misuse of and dependence on opioids: study of chronic pain patients. Can Fam Physician. Sep 2006;52(9):1081-1087.
45. Tacci JA, Webster BS, Hashemi L, et al. Healthcare utilization and referral patterns in the initial management of new-onset, uncomplicated, low back workers' compensation disability claims. J Occup Environ Med. Nov 1998;40(11):958-963.
46. Wasan AD, Jamison RN, Pham L, et al. Psychopathology predicts the outcome of medial branch blocks with corticosteroid for chronic axial low back or cervical pain: a prospective cohort study. BMC Musculoskelet Disord. 2009;10:22.
47. McCutcheon ME, Thompson WC, 3rd. CT scanning of lumbar discography. A useful diagnostic adjunct. Spine (Phila Pa 1976). Apr 1986;11(3):257-259.
48. Pauza K. PASSOR (Physiatric Association of Spine, Sports and Occupational Rehabilitation of the American Academy of Physical Medicine and Rehabilitation). Educational guidelines for the performance of spinal injection procedures. . June 2001. Updated April 2004.
49. Willems PC, Elmans L, Anderson PG, et al. Provocative discography and lumbar fusion: is preoperative assessment of adjacent discs useful? Spine (Phila Pa 1976). May 1 2007;32(10):1094-1099; discussion 1100.
50. Madigan L, Vaccaro AR, Spector LR, et al. Management of symptomatic lumbar degenerative disk disease. J Am Acad Orthop Surg. Feb 2009;17(2):102-111.
51. Kang CH, Kim YH, Lee SH, et al. Can magnetic resonance imaging accurately predict concordant pain provocation during provocative disc injection? Skeletal Radiol. Sep 2009;38(9):877-885.
52. Nordin M, Carragee EJ, Hogg-Johnson S, et al. Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). Feb 15 2008;33(4 Suppl):S101-122.
53. Kloth DS, Fenton DS, Andersson GB, et al. Intradiscal electrothermal therapy (IDET) for the treatment of discogenic low back pain:patient selection and indications for use. Pain Physician. Sep-Oct 2008;11(5):659-668.
54. Official Disability Guidelines (ODG). Discography, IDET, Percutaneous Disk Surgery. 05/11/2009.
55. Chou R, Atlas SJ, Stanos SP, et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). May 1 2009;34(10):1078-1093.
56. Freeman BJ, Mehdian R. Intradiscal electrothermal therapy, percutaneous discectomy, and nucleoplasty: what is the current evidence? Curr Pain Headache Rep. Jan 2008;12(1):14-21.
57. Rathmell JP, Saal JS, Saal J. Discography, IDET, Percutaneous Discectomy, and Nucleoplasty: Complications and Their Prevention. Pain Med. 2008;9(S1):S73-S81.
58. Carragee EJ, Alamin TF, Carragee JM. Low-pressure positive Discography in subjects asymptomatic of significant low back pain illness. Spine (Phila Pa 1976). Mar 1 2006;31(5):505-509.
59. Derby R, Lee SH, Kim BJ, et al. Pressure-controlled lumbar discography in volunteers without low back symptoms. Pain Med. May-Jun 2005;6(3):213-221; discussion 222-214.
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.
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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
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