Effective 07/31/26: Criteria Change for Disc Decompression Procedures

Clinical Policy: CP.MP.14 Disc Decompression
Procedures

• Policy/Criteria
  It is the policy of health
  plans affiliated with Centene Corporation® that open discectomy and microdiscectomy are medically necessary when meeting all of the following:
  1. Age ≥ 18 years;
  2. Diagnosis of herniated lumbar disc;
  3. Nerve root compression confirmed by imaging and one of the
     following:

1. Radiculopathy with motor deficit and
   one of the  following:
   1. Severe weakness in a nerve root distribution, as evidenced
      by: a score of ≤ 3 on the Medical Research Council (MRC) 0 to 5 muscle
      strength scale, or the inability to ambulate;
   2. Mild to moderate weakness in a nerve root distribution, as
      evidenced by a score of 4 on the MRC 0 to 5 muscle strength scale and one of
      the following:
      1. Worsening weakness or motor deficit;
      2. Member/enrollee has failed to respond to conservative
         therapy, within the last year, including all of the following:
         1. ≥ four weeks physical therapy or prescribed home exercise
            program, or documentation of member/enrollee’s inability to tolerate;
         2. ≥ four weeks activity modification;
         3. One of the following:
            1. Nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen
               ≥ three weeks unless contraindicated or not tolerated;
            2. Epidural steroid injection;
2. Radiculopathy with sensory deficit as evidenced by pain,
   parasthesias or numbness in a nerve root distribution, and member/enrollee
   has failed to respond to conservative therapy including all the following:
   1. four weeks physical therapy or prescribed home exercise
      program, or documentation of member/enrollee’s inability to tolerate;
   2. ≥ four weeks activity modification;
   3. One of the following:
      1. NSAID or acetaminophen ≥ three weeks unless contraindicated
         or not tolerated;
      2. Epidural steroid injection.

• It is the policy of health
  plans affiliated with Centene Corporation that the following minimally
  invasive procedures for spinal decompression have not been proven superior to other existing technologies:

1. Percutaneous lumbar discectomy (manual or automated [APLD]
   and/or MILD);
2. Percutaneous laser discectomy (PLD);
3. Laser-assisted disc decompression (LADD);
4. Percutaneous laser disc decompression (PLDD);
5. Percutaneous nuclectomy;
6. Percutaneous endoscopic discectomy;
7. Endoscopic laser percutaneous discectomy (LASE);
8. Endoscopic spinal surgery system;
9. Interspinous/interlaminar process stabilization/spacer
   device.