Category:  Surgery                                                                 

POLICY:

Automated percutaneous discectomy is considered investigational as a technique of intervertebral disc decompression in patients with back pain and/or radiculopathy related to disc herniation in the lumbar, thoracic or cervical spine.

Percutaneous endoscopic discectomy is considered investigational as a technique of intervertebral disc decompression in patients with back pain and/or radiculopathy related to disc herniation in the lumbar, thoracic or cervical spine.

DESCRIPTION OF PROCEDURE OR SERVICE:

Surgical management of herniated intervertebral discs most commonly involves discectomy or microdiscectomy, performed manually through an open incision. Automated percutaneous discectomy involves placement of a probe within the intervertebral disc under image guidance with aspiration of disc material using a suction cutting device. Removal of disc herniations under endoscopic visualization is also being investigated. Endoscopic discectomy involves the percutaneous placement of a working channel under image guidance, followed by visualization of the working space and instruments through an endoscope, and aspiration of disc material.

Back pain or radiculopathy related to herniated discs is an extremely common condition and a frequent cause of chronic disability. Although many cases of acute low back pain and radiculopathy will resolve with conservative care, surgical decompression is often considered when the pain is unimproved after several months and is clearly neuropathic in origin, resulting from irritation of the nerve roots. Open surgical treatment typically consists of discectomy in which the extruding disc material is excised. When performed with an operating microscope, the procedure is known as microdiscectomy.

Minimally invasive options have also been researched, in which some portion of the disc material is removed or ablated, although these techniques are not precisely targeted at the offending extruding disc material. Ablative techniques include laser discectomy and radiofrequency (RF) decompression. In addition, intradiscal electrothermal annuloplasty (also known as intradiscal electrothermal therapy [IDET]) is another minimally invasive approach to low back pain. In this technique, RF energy is used to treat the surrounding disc annulus. (See Medical Policy #090: Decompression of the Intervertebral Disc Using Laser Energy [Laser Discectomy] or Radiofrequency Coblation [Nucleoplasty] and Medical Policy #041: Percutaneous Intradiscal Electrothermal Annuloplasty (IDET), Radiofrequency Annuloplasty and Biacuplasty).

This policy addresses automated percutaneous and endoscopic discectomy, in which the disc decompression is accomplished by the physical removal of disc material rather than its ablation. Traditionally, discectomy is performed manually through an open incision, using cutting forceps to remove nuclear material from within the disc annulus. This technique has been modified by automated devices that involve placement of a probe within the intervertebral disc and aspiration of disc material using a suction cutting device. Endoscopic techniques may be intradiscal or may involve the extraction of non-contained and sequestered disc fragments from inside the spinal canal using an interlaminar or transforaminal approach. Following insertion of the endoscope, the decompression is performed under visual control.

KEY POINTS:

The most recent literature search was performed through April 15, 2024. Following is a summary of the key literature to date.

Summary of Evidence

For individuals who have herniated intervertebral disc(s) who receive automated percutaneous discectomy, the evidence includes randomized controlled trials (RCTs) and systematic reviews of RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment related morbidity. The published evidence is insufficient to evaluate the impact of automated percutaneous discectomy on the net health outcome. Evidence from small RCTs does not support the use of this procedure. Well-designed and executed RCTs are needed to determine the benefits and risks of this procedure. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have herniated intervertebral disc(s) who receive endoscopic percutaneous discectomy, the evidence includes a number of RCTs and systematic reviews of RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment related morbidity. Many of the more recent RCTs are conducted at institutions within China. There are few reports from the United States. Results do not reveal a consistently significant improvement in patient-reported outcomes and treatment-related morbidity with percutaneous endoscopic discectomy in comparison to other discectomy interventions. The evidence is insufficient to determine the effects of the technology on health outcomes.

Practice Guidelines and Position Statements

National Institute for Health and Care Excellence

The National Institute for Health and Clinical Excellence (NICE) published guidance in 2005 on automated percutaneous mechanical lumber discectomy, indicating that there is limited evidence of efficacy based on uncontrolled case series of heterogeneous groups of patients, and evidence from small randomized controlled trials shows conflicting results. The guidance states that in view of uncertainty about the efficacy of the procedure, it should not be done without special arrangements for consent and for audit or research. The guidance was considered for review in 2009, but did not meet the review criteria; the 2005 guidance is therefore considered current.

A NICE guideline on percutaneous transforaminal endoscopic lumbar discectomy for sciatica was published in 2016.  The guidance has stated that current evidence is adequate to support the use of percutaneous transforaminal endoscopic lumbar discectomy for sciatica. Choice of operative procedure (open discectomy, microdiscectomy, or percutaneous endoscopic approaches) may be influenced by symptoms, and location and size of prolapsed disc.

A NICE guidance on percutaneous interlaminar endoscopic lumbar discectomy for sciatica was published in 2016. The guidance stated that current evidence is adequate to support the use of percutaneous interlaminar endoscopic lumbar discectomy for sciatica. Choice of operative procedure (open discectomy, microdiscectomy, or percutaneous endoscopic approaches) may be influenced by symptoms, and location and size of prolapsed disc.

American Society of Interventional Pain Physicians

The 2013 guideline update from the American Society of Interventional Pain Physicians states that the evidence for percutaneous disc decompression with Dekompressor is limited. There were no recommended indications for Dekompressor.

North American Spine Society

In 2014, the North American Spine Society published clinical guidelines on the diagnosis and treatment of lumbar disc herniation.  Table 1 summarizes recommendations specific to endoscopic percutaneous discectomy and automated percutaneous discectomy.

Table 1. NASS Recommendations for Lumbar Disc Herniation with Radiculopathy

LOE: level of evidence; NASS: North American Spine Society

^a Grade B: fair evidence (level II or III studies with consistent findings; grade C: poor quality evidence (level IV or V studies).

^b Level of evidence II: lesser quality randomized controlled trial (e.g., <80% follow-up, no blinding, or improper randomization), prospective comparative study, systematic review of level II studies or level I studies with inconsistent results; level of evidence III: case control, retrospective, systematic review of level III studies; level of evidence IV: case series; level of evidence V: expert opinion.

American Pain Society

The 2009 clinical practice guidelines from the American Pain Society found insufficient evidence to evaluate alternative surgical methods to standard open discectomy and microdiscectomy, including laser or endoscopic-assisted techniques, various percutaneous techniques, coblation nucleoplasty, or the Dekompressor.

American Society of Pain and Neuroscience

The American Society of Pain and Neuroscience (ASPN; 2022) published clinical guidance for interventional treatments for low back pain. The guideline states that discectomy procedures (such as percutaneous and endoscopic disc procedures) have favorable safety and efficacy profiles for the treatment of lumbar disc herniation with persistent radicular symptoms; however, it is stated that further research is needed to evaluate complications rates in order for these procedures to supplant classic open microdiscectomy. Recommendations specific to percutaneous endoscopic discectomy are summarized in the table below.

Table 2. Recommendations for Percutaneous and Endoscopic Procedures

^a Grade B: (The ASPN Back Group recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

^b Evidence Level: I-A: At least one controlled and randomized clinical trial, properly designed

U.S. Preventive Services Task Force Recommendations

Not Applicable.

KEY WORDS:

Percutaneous endoscopic discectomy, herniated disc, LDH, lumbar disc herniation, Yess procedure, Yeung procedure, Yeung endoscopic spinal surgery, SED, selective endoscopic discectomy, PLD, percutaneous lumbar discectomy, IDET, intradiscal electrothermal therapy, IEA, intradiscal electrothermal annuloplasty, MED, microendoscopic discectomy, percutaneous radiofrequency thermo-modulation, percutaneous intradiscal radiofrequency thermocoagulation, Nucleoplasty, microdiscectomy, laser-assisted discectomy, LADD, open microdiscectomy, METRx™, Dekompressor, Stryker, Laurimed

APPROVED BY GOVERNING BODIES:

The Stryker DeKompressor® Percutaneous Discectomy Probe (Stryker), Herniatome Percutaneous Discectomy Device (Gallini Medical Devices), and the Nucleotome® (Clarus Medical) are examples of percutaneous discectomy devices that received clearance from the U.S. Food and Drug Administration (FDA) through the 510(k) process. Both have the same labeled intended use, i.e., “for use in aspiration of disc material during percutaneous discectomies in the lumbar, thoracic and cervical regions of the spine.”

A variety of endoscopes and associated surgical instruments have received marketing clearance through the FDA’s 510(k) process.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP: Special benefit consideration may apply. Refer to member’s benefit plan.

CURRENT CODING:

CPT codes:

HCPCS Codes:

REFERENCES:

1. Abudurexiti T, Qi L, Muheremu A, et al. Micro-endoscopic discectomy versus percutaneous endoscopic surgery for lumbar disk herniation. J Int Med Res. Sep 2018; 46(9): 3910-3917.
2. Ahn SS, Kim SH, Kim DW, et al. Comparison of Outcomes of Percutaneous Endoscopic Lumbar Discectomy and Open LumbarMicrodiscectomy for Young Adults: A Retrospective Matched Cohort Study. World Neurosurg. Feb 2016; 86: 250-8.
3. Ahn Y, Lee SG, Son S, et al. Transforaminal Endoscopic Lumbar Discectomy Versus Open Lumbar Microdiscectomy: AComparative Cohort Study with a 5-Year Follow-Up. Pain Physician. May 2019; 22(3): 295-304.
4. Akcakaya MO, Yorukoglu AG, Aydoseli A, et al. Serum creatine phosphokinase levels as an indicator of muscle injury following lumbardisc surgery: Comparison of fully endoscopic discectomy and microdiscectomy. Clin Neurol Neurosurg. Jun 2016; 145: 74-8.
5. Bai X, Lian Y, Wang J, et al. Percutaneous endoscopic lumbar discectomy compared with other surgeries for lumbar disc herniation: Ameta-analysis. Medicine (Baltimore). Mar 05 2021; 100(9): e24747.
6. Belykh E, Giers MB, Preul MC, et al. Prospective Comparison of Microsurgical, Tubular-Based Endoscopic, and Endoscopically Assisted Diskectomies: Clinical Effectiveness and Complications in Railway Workers. World Neurosurg. Jun 2016; 90: 273-280.
7. Casal-Moro R, Castro-Mendez M, Hernandez-Blanco M et al. Long-term outcome after microendoscopic diskectomy for lumbar disk herniation:  a prospective clinical study with a 5-year follow-up. Neurosurgery 2011: 68(6):1568-1575; discussion 1575.
8. Chang F, Zhang T, Gao G, et al. Therapeutic effect of percutaneous endoscopic lumbar discectomy on lumbar disc herniation and itseffect on oxidative stress in patients with lumbar disc herniation. Exp Ther Med. Jan 2018; 15(1): 295-299.
9. Chen HC, Lee CH, Wei L, et al. Comparison of percutaneous endoscopic lumbar discectomy and open lumbar surgery foradjacent segment degeneration and recurrent disc herniation. Neurol Res Int. 2015; 2015: 791943.
10. Chen Q, Qin L, Li MW, et al. Comparison of the therapeutic effect of percutaneous transforaminal endoscopic discectomy and posterior discectomy on senile single segmental lumbar disc herniation. Chin J Front Med Sci. 2018;10(2):60-64.
11. Chen Z, Zhang L, Dong J, et al. Percutaneous transforaminal endoscopic discectomy compared with microendoscopic discectomy for lumbar disc herniation: 1-year results of an ongoing randomized controlled trial. J Neurosurg Spine. Mar 2018;28(3):300-310.
12. Chen Z, Zhang L, Dong J, et al. Percutaneous Transforaminal Endoscopic Discectomy Versus MicroendoscopicDiscectomy for Lumbar Disc Herniation: Two-Year Results of a Randomized Controlled Trial. Spine (Phila Pa 1976). Apr15 2020; 45(8): 493-503.
13. Choi KC, Kim JS, Park CK. Percutaneous Endoscopic Lumbar Discectomy as an Alternative to Open Lumbar Microdiscectomyfor Large Lumbar Disc Herniation. Pain Physician. Feb 2016; 19(2): E291-300.
14. Choi KC, Lee JH, Kim JS, et al. Unsuccessful percutaneous endoscopic lumbar discectomy: a single-center experience of 10 228 cases. Neurosurgery. Apr 2015; 76(4):372-381.
15. Choi KC, Shim HK, Hwang JS, et al. Comparison of Surgical Invasiveness Between Microdiscectomy and 3 Different EndoscopicDiscectomy Techniques for Lumbar Disc Herniation. World Neurosurg. Aug 2018; 116: e750-e758.
16. Chou R, Loeser JD, Owens DK et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine 2009; 34(10):1066-1077.
17. Dai HJ, Zhang X, Wang LT, et al. The effect of percutaneoustransforaminal endoscopic discectomy (PTED) on seruminflammatoryfactors and pain in patients with lumbar disc herniationafter surgery. Int J Clin Exp Med 2020;13:597603.
18. Ding YZ, Hu JN, Zhou Y, et al. Study on the effect contrast between microendoscopic discectomy and percutaneous endoscopic lumbar discectomy using TESSYS technique for the treatment of lumbar disc herniation. J Cervicodynia & Lumbodynia. 2017;38(5):492-493.
19. Duan XF, Jin W, Chen JJ, et al. Contrast observation of comparing microendoscopic discectomy with percutaneous endoscopic lumbar discectomy for the treatment of simple lumbar disc herniation. Chin J Clin. 2016;10(1):144-147.
20. Gadjradj PS, Harhangi BS, Amelink J, et al. Percutaneous Transforaminal Endoscopic Discectomy Versus Open Microdiscectomy forLumbar Disc Herniation: A Systematic Review and Meta-analysis. Spine (Phila Pa 1976). Apr 15 2021; 46(8): 538-549.
21. Gadjradj PS, Rubinstein SM, Peul WC, et al. Full endoscopic versus open discectomy for sciatica: randomised controlled non-inferiority trial. BMJ. Feb 21 2022; 376: e065846.
22. Garg B, Nagraja UB, Jayaswal A. Microendoscopic versus open discectomy for lumbar disc herniation: a prospective randomized study. J Orthop Surg (Hong Kong) 2011; 19(1):30-34.
23. Gibson JN, Subramanian AS, Scott CE. A randomised controlled trial of transforaminal endoscopic discectomy vs microdiscectomy. Eur Spine J. Mar 2017; 26(3):847-856.
24. Haines SJ, Jordan N, Boen JR et al. Discectomy strategies for lumbar disc herniation: results of the LAPDOG trial. J Clin Neurosci 2002; 9(4):411-417.
25. Hermantin FU, Peters T, Quartararo L et al. A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. J Bone Joint surg Am 1999; 81(7):958-965.
26. Hsu HT, Chang SJ, Yang SS et al. Learning curve of full-endoscopic lumbar discectomy. Eur Spine J Apr 2013l 22(4):727-33.
27. Huang TJ, Hsu RW, Li YY, et al. Less systemic cytokine response in patients following microendoscopic versus open lumbardiscectomy. J Orthop Res. Mar 2005; 23(2): 406-11.
28. Hussein M, Abdeldayem A, Mattar MM. Surgical technique and effectiveness of microendoscopic discectomy for large uncontained lumbar disc herniations: a prospective, randomized, controlled study with 8 years of follow-up. Eur Spine J. Sep 2014; 23(9):1992-1999.
29. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
30. Jarebi M, Awaf A, Lefranc M, et al. A matched comparison of outcomes between percutaneous endoscopic lumbardiscectomy and open lumbar microdiscectomy for the treatment of lumbar disc herniation: a 2-year retrospective cohortstudy. Spine J. Jan 2021; 21(1): 114-121.
31. Jeong, J.S.; Lee, S.H.; Lee, S.J.; Hwang, B.W. The Clinical Comparison between Open Surgery and PercutaneousEndoscopic Lumbar Discectomy in Extraforaminal Lumbar Disc Herniation. J. Korean Neurosurg. Soc. 2006, 39, 413418.
32. Jing Z, Li L, Song J. Percutaneous transforaminal endoscopic discectomy versus microendoscopic discectomy for upperlumbar disc herniation: a retrospective comparative study. Am J Transl Res. 2021; 13(4): 3111-3119.
33. Kim CH, Chung CK, Choi Y, et al. The Long-term Reoperation Rate Following Surgery for Lumbar Herniated IntervertebralDisc Disease: A Nationwide Sample Cohort Study With a 10-year Follow-up. Spine (Phila Pa 1976). Oct 01 2019; 44(19):1382-1389.
34. Kim MJ, Lee SH, Jung ES, et al. Targeted percutaneous transforaminal endoscopic diskectomy in 295 patients: comparison with resultsof microscopic diskectomy. Surg Neurol. Dec 2007; 68(6): 623-631.
35. Kleinpeter G, Markowitsch MM, Bock F. Percutaneous endoscopic lumbar discectomy: minimally invasive, but perhaps onlyminimally useful?. Surg Neurol. Jun 1995; 43(6): 534-9; discussion 540-1.
36. Krappel FA, Schmitz R, Bauer E, et al. Open or endoscopicnucleotomy?. Orthopadische Praxis 2001;37:1649.
37. Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. Jan 2014; 14(1):180-191.
38. Lee DY, Lee SH. Learning curve for percutaneous endoscopic lumbar discectomy. Neurol Med Chir (Tokyo) 2008; 48(9):383-388; discussion 388-389.
39. Lee SH, Chung SE, Ahn Y, et al. Comparative radiologic evaluation of percutaneous endoscopic lumbar discectomy and open microdiscectomy: a matched cohort analysis. Mt Sinai J Med. Sep 2006; 73(5): 795-801.
40. Lee DY, Shim CS, Ahn Y, et al. Comparison of percutaneous endoscopic lumbar discectomy and open lumbar microdiscectomyfor recurrent disc herniation. J Korean Neurosurg Soc. Dec 2009; 46(6): 515-21.
41. Lewis RA, Williams NH, Sutton AJ, et al. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. Spine J. Jun 1 2015; 15(6):1461-1477.
42. Li H, Jiang C, Mu X, et al. Comparison of MED and PELD in the Treatment of Adolescent Lumbar Disc Herniation: A 5-Year Retrospective Follow-Up. World Neurosurg. Apr 2018; 112: e255-e260.
43. Li M, Yang H, Yang Q. Full-Endoscopic Technique Discectomy Versus Microendoscopic Discectomy for the Surgical Treatment of Lumbar Disc Herniation. Pain Physician. Jul-Aug 2015; 18(4): 359-63.
44. Li ZY, Guo PG, Han D, et al. Analysis of curative effects and prognosis in different procedures of discectomy for patients with lumbar disc herniation. J Clin Med Pract. 2017;21(15):149-150,158.
45. Liu HP, Hao DJ, Wang XD, et al. Comparison of two surgeries in treatment of lumbar disc herniation. Chin J Pain Med. 2017;23(6):438-442.
46. Liu Y, Kim Y, Park CW, et al. Interlaminar Endoscopic Lumbar Discectomy Versus Microscopic Lumbar Discectomy: A PreliminaryAnalysis of L5-S1 Lumbar Disc Herniation Outcomes in Prospective Randomized Controlled Trials. Neurospine. Dec 2023; 20(4): 1457-1468.
47. Liu X, Yuan S, Tian Y, et al. Comparison of percutaneous endoscopic transforaminal discectomy, microendoscopicdiscectomy, and microdiscectomy for symptomatic lumbar disc herniation: minimum 2-year follow-up results. J NeurosurgSpine. Mar 2018; 28(3): 317-325.
48. Liu C, Zhou Y. Percutaneous Endoscopic Lumbar Diskectomy and Minimally Invasive Transforaminal Lumbar Interbody Fusion forRecurrent Lumbar Disk Herniation. World Neurosurg. Feb 2017; 98: 14-20.
49. Liu T, Zhou Y, Wang J, et al. Clinical efficacy of three different minimally invasive procedures for far lateral lumbar discherniation. Chin Med J (Engl). Mar 2012; 125(6): 1082-8.
50. Luo DK, Zhou NX, Zhao HW, et al. Clinical effectiveness of minimally invasive treatment for lumbar disc herniation. Orthopaedics. 2017;8(6):439-444.
51. Ma C, Li H, Zhang T, et al. Comparison of Percutaneous Endoscopic Interlaminar Discectomy and Open FenestrationDiscectomy for Single-Segment Huge Lumbar Disc Herniation: A Two-year Follow-up Retrospective Study. J Pain Res.2022; 15: 1061-1070.
52. Manchikanti L, Abdi S, Alturi S, et al. An Update of Comprehensive Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain. Part II: Guidance and Recommendations. Pain Physician. April 2013; 16:S49-S283.
53. Martin-Laez R, Martinez-Agueros JA, Suarez-Fernandez D, et al. Complications of endoscopic microdiscectomy using theEASYGO! system: is there any difference with conventional discectomy during the learning-curve period?. Acta Neurochir(Wien). Jun 2012; 154(6): 1023-32.
54. Mayer HM, Brock M. Percutaneous endoscopic discectomy: surgical technique and preliminary results compared tomicrosurgical discectomy. J Neurosurg. Feb 1993; 78(2): 216-25.
55. Meyer G, DA Rocha ID, Cristante AF, et al. Percutaneous Endoscopic Lumbar Discectomy Versus Microdiscectomy for the Treatment of Lumbar Disc Herniation: Pain, Disability, and Complication Rate-A Randomized Clinical Trial. Int J SpineSurg. Feb 2020; 14(1): 72-78.
56. National Institute for Health and Clinical Excellence. Automated percutaneous mechanical lumbar discectomy-guidance [IPG141]. 2005. guidance.nice.org.uk/IPG141/Guidance/pdf/English.
57. National Institute for Health and Care Excellence (NICE). Percutaneous interlaminar endoscopic lumbar discectomy for sciatica [IPG555]. 2016; https://www.nice.org.uk/guidance/ipg555.
58. National Institute for Health and Care Excellence (NICE). Percutaneous transforaminal endoscopic lumbar discectomy for sciatica [IPG556]. 2016; https://www.nice.org.uk/guidance/ipg556.
59. Ohya J, Oshima Y, Chikuda H, et al. Does the microendoscopic technique reduce mortality and major complications in patients undergoing lumbar discectomy? A propensity score-matched analysis using a nationwide administrative database. Neurosurg Focus. Feb 2016; 40(2): E5.
60. Pan Z, Ha Y, Yi S, et al. Efficacy of Transforaminal Endoscopic Spine System (TESSYS) Technique in Treating Lumbar DiscHerniation. Med Sci Monit. Feb 18 2016; 22: 530-9.
61. Pan L, Zhang P, Yin Q. Comparison of tissue damages caused by endoscopic lumbar discectomy and traditional lumbar discectomy: a randomised controlled trial. Int J Surg. 2014; 12(5): 534-7.
62. Phan K, Xu J, Schultz K, et al. Full-endoscopic versus micro-endoscopic and open discectomy: A systematic review and meta-analysis of outcomes and complications. Clin Neurol Neurosurg. Mar 2017; 154:1-12.
63. Qu JX, Li QZ, Chen M : Comparative study of PTED and MED for monosegment lumbar disc herniation. Chin J Bone Joint Inj32 : 70-71, 2017
64. Qu JX, Li QZ, Chen M, et al. Comparison of the efficacies between percutaneous transforaminal endoscopic discectomy and microendoscopic discectomy for the treatment of single-segmental lumbar disc herniation. Chin J Bone Jt Inj. 2017;32(1):70-71.
65. Rajamani PA, Goparaju P, Kulkarni AG, et al. A 2-Year Outcomes and Complications of Various Techniques of LumbarDiscectomy: A Multicentric Retrospective Study. World Neurosurg. Dec 2021; 156: e319-e328.
66. Ran B, Wei J, Yang J, et al. Quantitative Evaluation of the Trauma of CT Navigation PELD and OD in the Treatment of HLDH: A Randomized, Controlled Study. Pain Physician. Jul 2021; 24(4): E433-E441.
67. Righesso O, Falavigna A, Avanzi O. Comparison of open discectomy with microendoscopic discectomy in lumbar discherniations: results of a randomized controlled trial. Neurosurgery. Sep 2007; 61(3): 545-9; discussion 549.
68. Ruetten S, Komp M, Merk H et al. Full-endoscopic cervical posterior foraminotomy for the operation of lateral disc herniations using 5.9-mm endoscopes: a prospective, randomized, controlled study. Spine 2008; 33(9):940-948.
69. Ruetten S, Komp M, Merk H et al. Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine 2008; 33(9):931-939.
70. Ruetten S, Komp M, Merk H et al. Recurrent lumbar disc herniation after conventional discectomy: a prospective, randomized study comparing full-endoscopic interlaminar and transforaminal versus microsurgical revision. J Spinal Disord Tech 2009; 22(2):122-129.
71. Ruetten S, Komp M, Merk H, et al. Use of newly developed instruments and endoscopes: full-endoscopic resection of lumbardisc herniations via the interlaminar and lateral transforaminal approach. J Neurosurg Spine. Jun 2007; 6(6): 521-30.
72. Saghebdoust S, Khadivar F, Ekrami M, et al. Transforaminal Endoscopic Lumbar Diskectomy versus Open Microdiskectomy forSymptomatic Lumbar Disk Herniation: A Comparative Cohort Study on Costs and Long-Term Outcomes. J Neurol Surg A Cent EurNeurosurg. Oct 25 2023.
73. Sasaoka R, Nakamura H, Konishi S, et al. Objective assessment of reduced invasiveness in MED. Compared with conventionalone-level laminotomy. Eur Spine J. May 2006; 15(5): 577-82.
74. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) Evidence-Based ClinicalGuideline of Interventional Treatments for Low Back Pain. J Pain Res. 2022; 15: 3729-3832.
75. Schizas C, Tsiridis E, Saksena J. Microendoscopic discectomy compared with standard microsurgical discectomy for treatmentof uncontained or large contained disc herniations. Neurosurgery. Oct 2005; 57(4 Suppl): 357-60; discussion 357-60.
76. Shi R, Wang F, Hong X, et al. Comparison of percutaneous endoscopic lumbar discectomy versus microendoscopic discectomy for the treatment of lumbar disc herniation: a meta-analysis. Int Orthop. Apr 2019; 43(4): 923-937.
77. Sinkemani A, Hong X, Gao ZX, et al. Outcomes of Microendoscopic Discectomy and Percutaneous  Transforaminal Endoscopic Discectomy for the Treatment of Lumbar Disc Herniation: A Comparative Retrospective Study. Asian Spine J. Dec 2015; 9(6): 833-40.
78. Song HP, Sheng HF, Xu WX. A case-control study on the treatment of protrusion of lumbar intervertebral disc through PELD and MED. Exp Ther Med. Oct 2017; 14(4):3708-3712.
79. Sun Y, Zhang W, Qie S, et al. Comprehensive comparing percutaneous endoscopic lumbar discectomy with posteriorlumbar internal fixation for treatment of adjacent segment lumbar disc prolapse with stable retrolisthesis: A retrospectivecase-control study. Medicine (Baltimore). Jul 2017; 96(29): e7471.
80. Tacconi L, Giordan E. Endoscopic transforaminal discectomy vs.far lateral discectomy for extraforaminal disc protrusions:ourexperience. NeuroQuantology 2019;17:1822.
81. Tacconi L, Signorelli F, Giordan E. Is Full Endoscopic Lumbar Discectomy Less Invasive Than Conventional Surgery? A RandomizedMRI Study. World Neurosurg. Jun 2020; 138: e867-e875.
82. Tao XZ, Jing L, Li JH. Therapeutic effect of transforaminal endoscopic spine system in the treatment of prolapse of lumbar intervertebraldisc. Eur Rev Med Pharmacol Sci. Jul 2018; 22(1 Suppl): 103-110.
83. Teli M, Lovi A, Brayda-Bruno M et al. Higher risk of dural tears and recurrent herniation with lumbar micro-endoscopic discectomy. Eur Spine J 2010; 19(3):443-450.
84. Tenenbaum S, Arzi H, Herman A et al. Percutaneous posterolateral transforaminal endoscopic discectomy: clinical outcome, complications, and learning curve evaluation. Surg Technol Int 2011; XXI: 278-283.
85. Tu Z, Li YW, Wang B, et al. Clinical Outcome of Full-endoscopic Interlaminar Discectomy for Single-level Lumbar Disc Herniation: A Minimum of 5-year Follow-up. Pain Physician. Mar 2017; 20(3): E425-E430.
86. Wang H, Cheng J, Xiao H, et al. Adolescent lumbar disc herniation: experience from a large minimally invasive treatment centre forlumbar degenerative disease in Chongqing, China. Clin Neurol Neurosurg. Aug 2013; 115(8): 1415-9.
87. Wang F, Guo D, Sun T, et al. A comparative study on short-term therapeutic effects of percutaneous transforaminal endoscopic discectomy and microendoscopic discectomy on lumbar disc herniation. Pak J Med Sci. Mar-Apr 2019; 35(2): 426-431.
88. Wang SF, Hung SF, Tsai TT, et al. Better Functional Outcome and Pain Relief in the Far-Lateral-Outside-in PercutaneousEndoscopic Transforaminal Discectomy. J Pain Res. 2021; 14: 3927-3934.
89. Wang B, Lu G, Patel AA et al. An evaluation of the learning curve for a complex surgical technique: the full endoscopic interlaminar approach for lumbar disc herniations. Spine J 2011; 11(2):122-130.
90. Wang H, Song Y, Cai L. Effect of percutaneous transforaminallumbar spine endoscopic discectomy on lumbar disc herniationand itsinfluence on indexes of oxidative stress. Biomed Res 2017;28.
91. Wang M, Zhou Y, Wang J, et al. A 10-year follow-up study on long-term clinical outcomes of lumbar microendoscopic discectomy. J Neurol Surg A Cent Eur Neurosurg. Aug 2012; 73(4):195-198.
92. Wu XC, Zhou Y, Li CQ. Percutaneous tranforaminal endoscopic discectomy versus microendoscopic discectomy for lumbardisc herniation: a prospective randomized controlled study. J Third Mil Med Univ. 2009;31(9):843-846.
93. Wu YM, Bai M, Yin HP, et al. Comparison of the efficacies between two kinds of minimally invasive procedures for the treatment of simple lumbar disc herniation. J Pract Orthop. 2018;24(4):357-360.
94. Xu J, Li Y, Wang B, et al. Minimum 2-Year Efficacy of Percutaneous Endoscopic Lumbar Discectomy versus Microendoscopic Discectomy: A Meta-Analysis. World Neurosurg. Feb 26 2020; 138: 19-26.
95. Xu G, Zhang C, Zhu K, et al. Endoscopic removal of nucleus pulposus of intervertebral disc on lumbar intervertebral disc protrusion and the influence on inflammatory factors and immune function. Exp Ther Med. Jan 2020; 19(1): 301-307.
96. Yang L, Liao XQ, Zhao XJ, et al. Comparison of surgical outcomes between percutaneous transforaminal endoscopic discectomy and micro-endoscopic discectomy for lumbar disc herniation. China J Endosc. 2015;21(9):962-965.
97. Yang X, Zhang S, Su J, et al. Comparison of Clinical and Radiographic Outcomes Between Transforaminal Endoscopic LumbarDiscectomy and Microdiscectomy: A Follow-up Exceeding 5 Years. Neurospine. Mar 2024; 21(1): 303-313.
98. Yao Y, Zhang H, Wu J, et al. Minimally Invasive Transforaminal Lumbar Interbody Fusion Versus Percutaneous Endoscopic LumbarDiscectomy: Revision Surgery for Recurrent Herniation After Microendoscopic Discectomy. World Neurosurg. Mar 2017; 99: 89-95.
99. Yao Y, Zhang H, Wu J, et al. Comparison of Three Minimally Invasive Spine Surgery Methods for Revision Surgery for RecurrentHerniation After Percutaneous Endoscopic Lumbar Discectomy. World Neurosurg. Apr 2017; 100: 641-647.e1.
100. Yoon SM, Ahn SS, Kim KH, et al. Comparative Study of the Outcomes of Percutaneous Endoscopic Lumbar Discectomy and Microscopic Lumbar Discectomy Using the Tubular Retractor System Based on the VAS, ODI, and SF-36. Korean J Spine. Sep 2012; 9(3): 215-22.
101. Yu, PP, Qiang, HH, Zhou, JJ, Huang, PP. Percutaneous Transforaminal Endoscopic Discectomy versus Micro-Endoscopic Discectomy for Lumbar Disc Herniation.. Med. Sci. Monit., 2019 Mar 31;25:2320-2328.
102. Zhao XM, Chen AF, Lou XX, et al. Comparison of Three Common Intervertebral Disc Discectomies in the Treatment ofLumbar Disc Herniation: A Systematic Review and Meta-Analysis Based on Multiple Data. J Clin Med. Nov 08 2022;11(22).
103. Zhao XW, Han K, Ji ZW, et al. Comparison of efficacy between microendoscopic discectomy and percutaneous endoscopic lumbar discectomy for treatment of lumbar disc herniation. Prog Mod Biomed. 2016;16(23):4454-4457.
104. Zhao W, Li CQ, Zhou Y, Wang J, Zheng WJ : Surgical treatment of the lumbar disc herniated discs using transforaminal endoscopicsurgerysystem. Orthop J China 20 : 1191-1195, 2012.
105. Zhao XM, Yuan QL, Liu L, et al. Is It Possible to Replace Microendoscopic Discectomy with Percutaneous Transforaminal Discectomy for Treatment of Lumbar Disc Herniation? A Meta-Analysis Based on Recurrence and Revision Rate. J Korean Neurosurg Soc. Jul 2020; 63(4): 477-486.

POLICY HISTORY:

Medical Policy Group, September 2003

Medical Policy Administration Committee, October 2003

Available for comment October 20-December 3, 2003

Medical Policy Group, August 2005 (1)

Medical Policy Group, January 2006(1)

Medical Policy Administration Committee, February 2006

Available for comment March 14-April 27, 2006

Medical Policy Group, January 2007 (1)

Medical Policy Group, January 2009 (1)

Medical Policy Group, January 2010 (1)

Medical Policy Group, December 2011 (1): 2012 Updates – Verbiage change to 62287

Medical Policy Group, January 2012 (1): Update to Title, Descriptions, Key Points and References related to endoscopic percutaneous discectomy; no change in policy statement.

Medical Policy Panel, April 2013

Medical Policy Group, September 2013 (2): Policy statement clarified to read “back pain and/or radiculopathy”, all references to open procedures removed, and policy statement specific to Yeung procedure removed.  Title changed to add “Automated”.   Description, Key Points, and References updated to support policy statements.

Medical Policy Administration Committee, September 2013

Available for comments September 19 through November 2, 2013

Medical Policy Panel, March 2014

Medical Policy Group, March 2014 (4): updated Key Points and References. No changes to the policy at this time.

Medical Policy Panel, April 2015

Medical Policy Group, May 2015 (2): 2015 Updates to Key Points and References, no change to policy.

Medical Policy Panel, April 2016

Medical Policy Group, April 2016 (7): 2016 Updates to Key Points and References, no change to policy statement.

Medical Policy Group, December 2016: 2017 Annual Coding Update.  Added new cpt code 62380 to current coding. Updated verbiage for revised CPT code 62287. Updated verbiage for revised cpt code 0274T.

Medical Policy Panel, April 2017

Medical Policy Group, April 2017 (7): Updates to Description, Key Points, Approved by Governing Bodies, and References; added “Percutaneous” to title; added “Percutaneous” to 2nd policy statement. No change in policy intent.

Medical Policy Panel, December 2018

Medical Policy Group, January 2019 (7): Updates to Key Points and References. No change in Policy Statement.

Medical Policy Panel, June 2019

Medical Policy Group, June 2019 (7): Updates to Key Points and References. No change in Policy Statement.

Medical Policy Panel, June 2020

Medical Policy Group, August 2020 (7): Updates to Key Points and References. No change in Policy Statement.

Medical Policy Panel, June 2021

Medical Policy Group, July 2021 (7): Updates to Key Points and References. Removed “not medically necessary” verbiage from Policy Statement. No change in intent.

Medical Policy Panel, June 2022

Medical Policy Group, August 2022 (7): Updates to Key Points and References. No change in Policy Statement.

Medical Policy Panel, June 2023

Medical Policy Group, July 2023 (7): Updates to Key Points, Benefit Application, and References. Clarification to CPT 62287- removed “(e.g., manual or automated percutaneous discectomy, percutaneous laser discectomy).” No change to Policy Statement.

Medical Policy Panel, June 2024

Medical Policy Group, June 2024 (7): Updates to Key Points and References. No change in Policy Statement.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1.  The technology must have final approval from the appropriate government regulatory bodies;
2.  The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3.  The technology must improve the net health outcome;
4.  The technology must be as beneficial as any established alternatives;
5.  The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1.  In accordance with generally accepted standards of medical practice; and
2.  Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3.  Not primarily for the convenience of the patient, physician or other health care provider; and
4.  Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.