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.
5.15 Transcutaneous
Electrical Nerve Stimulation (TENS) for the treatment of acute,
subacute, and chronic low back pain (LBP) is excluded from coverage.
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.
6.14 June
1, 2020, for the exclusion of TENS for the treatment of acute, subacute,
and chronic LBP.