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.
5.16 Platelet-rich plasma
(PRP) is unproven for all indications.
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.