Lumbar discectomy
Traditional approach (open)
Automated percutaneous discectomy
Automated endoscopic discectomy
(see Policy Guidelines section) may be considered medically necessary for the treatment of lumbar herniated disc when the following criteria are met:
Signs and symptoms of radiculopathy on history and physical exam (see Policy Guidelines section).
One of the following clinical presentations is present:
Rapidly progressing neurologic deficits; OR
Persistent debilitating back or leg pain that is refractory to at least 6 weeks of conservative therapy (see Policy Guidelines section).
Documentation of nerve root compression on imaging (magnetic resonance imaging or computed tomography) at a level that corresponds with the patient’s symptoms (see Policy Guidelines section).
Lumbar discectomy is not medically necessary for the treatment of lumbar herniated disc when the above criteria are not met.
Cervical discectomy
Traditional approach (open)
Automated percutaneous discectomy
Automated endoscopic discectomy
(see Policy Guidelines section) may be considered medically necessary for the treatment of cervical herniated disc when the following criteria are present:
Signs and symptoms of radiculopathy and/or myelopathy on history and physical exam (see Policy Guidelines section).
One of the following clinical presentations is present:
Rapidly progressing neurologic deficits; OR
Persistent debilitating neck, back, or arm pain that is refractory to at least 6 weeks of conservative therapy (see Policy Guidelines section); OR
Persistent or progressive symptoms of myelopathy that are refractory to at least 6 weeks of conservative therapy (see Policy Guidelines section).
Documentation of nerve root compression on imaging (magnetic resonance imaging or computed tomography) at a level that corresponds with the patient’s symptoms (see Policy Guidelines section).
Cervical discectomy is not medically necessary for the treatment of cervical herniated disc when the above criteria are not met.
Discectomy is considered investigational for all other indications.
