1.0 CPT
PROCEDURE CODES
20005 - 20551, 20555 - 22328,
22510 - 22515, 22532 - 22856, 22858, 22859, 22861, 22864 - 27138, 27140, 27146
- 27179, 27181 - 29862, 29870 - 29916, 29999
2.0 HCPCS
CODES
S2112, S2118, S2325
3.0 DESCRIPTION
The musculoskeletal system pertains to or comprises
the skeleton and the muscles.
4.0 POLICY
4.1 Services
and supplies required in the diagnosis and treatment of illness
or injury involving the musculoskeletal system are covered. U.S.
Food and Drug Administration (FDA) approved surgically implanted
devices are also covered.
4.2 Autologous cultured chondrocytes
on porcine collagen membrane (i.e. Matrix-Induced Autologous Chondrocyte
Implantation [MACI]) to treat cartilage defects of the knee is proven.
4.3 Single
or multilevel anterior cervical microdiskectomy with allogeneic
or autogeneic iliac crest grafting and anterior plating is covered
for the treatment of cervical spondylosis.
4.4 Percutaneous vertebroplasty
(Current Procedural Terminology (CPT) procedure codes 22510-22512)
and balloon kyphoplasty (CPT procedure codes 22513-22515) are covered
for the treatment of painful osteolytic lesions and osteoporotic
compression fractures refractory to conservative medical treatment.
4.5 Total Ankle
Replacement (TAR) (CPT procedure codes 27702 and 27703) surgery
is covered if the device is FDA approved and the use is for an FDA
approved indication. However, a medical necessity review is required
in case of marked varus or valgus deformity.
4.6 Core decompression
of the femoral head (hip) for early (precollapse stage I or II)
avascular necrosis may be considered for cost-sharing (Healthcare
Common Procedure Coding System (HCPCS) code S2325).
4.7 Single-level,
cervical Total Disc Replacement (TDR) (CPT procedure code 22856)
and two-level, cervical TDR (CPT procedure code 22858) using an
FDA approved cervical artificial intervertebral disc for the treatment
of cervical Degenerative Disc Disease (DDD), intractable radiculopathy,
and/or myelopathy is covered if the disc is used in accordance with
its FDA labeled indications.
4.8 High Energy Extracorporeal
Shock Wave Therapy (HE ESWT) for the treatment of plantar fasciitis
is covered when all of the following conditions are met:
• Patients
have chronic plantar fasciitis of at least six months duration;
• Patients have undergone
and failed six months of appropriate conservative therapy; and
• HE ESWT is defined
as Energy Flux Density (EFD) greater than 0.12 millijoules per square millimeter
(mJ/mm2).
4.9 Meniscal allograft transplant of the knee is
covered.
4.10 Hip resurfacing (CPT procedure
codes 27125 and 27130, and HCPCS S2118) with an FDA approved device
is proven for the treatment of Degenerative Joint Disease (DJD)
of the hip in patients who are less than 65 years old and who meet
all of the following criteria:
• Have
chronic, persistent pain and/or disability;
• Are
otherwise healthy and active;
• Have
normal proximal femoral bone geometry and bone quality; and
• Would
otherwise receive a conventional Total Hip Replacement (THR), but
are likely to outlive a conventional THR implant system’s expected
life.
4.11 Minimally Invasive Surgery
(CPT procedure code 27279) for treatment of sacroiliac joint pain
is proven.
4.12 Autologous Chondrocyte Implantation
(ACI), with Carticel, for the repair of patellar cartilage lesions
is proven.
4.13 Single-level, lumbar TDR (CPT
procedure code 22857) using an FDA approved lumbar artificial intervertebral
disc for the treatment of single-level, lumbar DDD in patients who
have failed conservative treatment is covered if the disc is used
in accordance with its FDA labeled indications.
4.14 Open, arthroscopic, and combined hip surgery
(CPT 27140, 27179, 29862, 29914-16) for the treatment of Femoroacetabular
Impingement (FAI) is proven and covered when all of the following criteria
are met:
• Moderate to severe
and persistent activity limiting hip pain that is worsened by flexion activities.
• Physical
examination is consistent with the diagnosis of FAI with at least
one positive test required:
• Positive
impingement sign (pain when bringing the knee up towards the chest
and then rotating it inward towards the opposite shoulder); or
• Flexion
Abduction External Rotation (FABER) provocation test (the test is
positive if it elicits similar pain as complained by the patient
or range of motion of the hip is significantly decreased compared
to the contra lateral hip); or
• Posterior
inferior impingement test (the test is positive if it elicits similar
pain as complained by the patient).
• Failure
to improve with greater than three months of conservative treatment
(e.g., physical therapy, activity modification, non-steroidal anti-inflammatory
medications, intra-articular injection, etc.); and
• Radiographic
evidence of FAI; and
• Absence of advanced
arthritis.
5.0 EXCLUSIONS
5.1 Ligament replacement with absorbable copolymer
carbon fiber scaffold is unproven.
5.2 Prolotherapy, joint sclerotherapy and ligamentous
injections with sclerosing agents (HCPCS procedure code M0076) are
unproven.
5.3 Trigger point injection (CPT
procedure codes 20552 and 20553) for migraine headaches.
5.4 Cervical TDR, three or more levels (CPT procedure
code 0375T), is unproven.
5.5 Removal of cervical TDR, three or more levels (CPT
procedure code 0095T), is unproven. Also, see
Section 1.1.
5.6 Lumbar TDR, two or more levels (CPT procedure
codes 0163T and 0165T) is unproven.
5.7 Removal of lumbar TDR, each additional level
(CPT procedure code 0164T), is unproven.
5.8 Low Energy (LE) or radial ESWT for the treatment
of plantar fasciitis is unproven. Any form of ESWT for the treatment
of lateral epicondylitis is unproven.
5.9 Interlaminar/interspinous process devices (CPT
procedure codes 22867-22870, and HCPCS code C1821), including, but
not limited to, interspinous distraction devices and interspinous
stabilizers, for the treatment of neurogenic claudication and/or lumbar
spinal stenosis are unproven.
5.10 Osteochondral allograft of the humeral head
with meniscal transplant and glenoid microfracture in the treatment
of shoulder pain and instability is unproven.
5.11 Thermal Intradiscal Procedures (TIPs) (CPT
procedure codes 22526, 22527, 62287, and Healthcare Common Procedure
Coding System (HCPCS) code S2348) are unproven. TIPs are also known as:
Intradiscal Electrothermal Annuloplasty (IEA), Intradiscal Electrothermal
Therapy (IDET), Intradiscal Thermal Annuloplasty (IDTA), Percutaneous
Intradiscal Radiofrequency Thermocoagulation (PIRFT), Coblation
Percutaneous Disc Decompression, Nucleoplasty (also known as Percutaneous Radiofrequency
(RF) Thermomodulation or Percutaneous Plasma Diskectomy), Radiofrequency Annuloplasty
(RA), Intradiscal Biacuplasty (IDB), Percutaneous (or Plasma) Disc
Decompression (PDD), Targeted Disc Decompression (TDD), Cervical
Intradiscal RF Lesioning.
5.12 Spinal manipulation under anesthesia (CPT procedure
codes 00640 and 22505) for the treatment of back pain is unproven.
5.13 Minimally Invasive Lumbar Decompression (mild®)
for the treatment of DDD and/or spinal stenosis is unproven.
5.14 Athletic pubalgia surgery is unproven.
6.0 EFFECTIVE
DATEs
6.1 February 6, 2006, for percutaneous vertebroplasty
and balloon kyphoplasty.
6.2 May 1, 2008, for TAR.
6.3 May 1,
2008, for core decompression of the femoral head.
6.4 December
24, 2012, for single-level, cervical TDR using an FDA approved cervical
artificial intervertebral disc.
6.5 December 2, 2013, for HE ESWT
for plantar fasciitis.
6.6 May 21, 2014, for hip resurfacing
for treatment of DJD of the hip.
6.7 May 1, 2015, for meniscal allograft transplant
of the knee.
6.8 July 27, 2015, for two-level
cervical TDR using an FDA approved cervical artificial intervertebral disc.
6.9 August 23, 2016, Minimally Invasive Surgery
(CPT procedure code 27279) for the treatment of sacroiliac joint
pain is proven.
6.10 May 7, 2016, for ACI surgery,
with Carticel, for the repair of patellar cartilage lesions.
6.11 December 13, 2016, for autologous cultured
chondrocytes on porcine collagen membrane.
6.12 November 16, 2017, for single-level, lumbar
TDR using an FDA approved lumbar artificial intervertebral disc.
6.13 May 4, 2017, for open, arthroscopic and combined
hip surgery for treatment of FAI.