CPT 0195T, 0309T, 22586, 22899 - Lumbosacral Interbody Fusion

Coding Code Description CPT

0195T Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed;

L5-S1 interspace
0196T Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed;

L4-L5 interspace (List separately in addition to code for primary procedure)

0309T Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (List separately in addition to code for primary procedure) (code terminated 1/1/18, replaced with 22899)

22586 Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace.

22899 Unlisted procedure, spine


Lumbosacral Interbody Fusion



Introduction

Fusing the bones at the lowest part of the back may be one choice to treat lower back (lumbar) pain. When this kind of fusion is needed, it’s usually done by making an opening (an incision) through the back muscles and other tissue. In axial lumbar interbody fusion, the incision is made in the buttock. A tube, long enough to reach the spine, is inserted upwards along a specific path. Special tools are then threaded through the tube to reach the disc that sits between the bones.

The surgeon cuts way the damaged disk and removes it through the tube. The tube also guides the path for the bone graft material and a small implant. The bone graft material promotes bone growth, and over time the two bones grow together and are permanently joined. Because more studies are needed to determine the risks and benefits of this procedure compared to other methods of lumbar fusion, this service is considered unproven (investigational).

Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered.


Policy Coverage Criteria Service Investigational Axial lumbosacral interbody fusion

Axial lumbosacral interbody fusion is considered investigational.


Evidence Review Description

Axial lumbosacral interbody fusion (LIF; also called presacral, transsacral or paracoccygeal interbody fusion) is a minimally invasive technique designed to provide anterior access to the L4-S1 disc spaces for interbody fusion, while minimizing damage to muscular, ligamentous, neural, and vascular structures. It is performed under fluoroscopic guidance.

Background

Interbody fusion is a surgical procedure that fuses 2 adjacent vertebral bodies of the spine. Lumbar interbody fusion may be performed in patients with spinal stenosis and instability, spondylolisthesis, scoliosis, following discectomy, or for adjacent-level disc disease.

Axial Lumbosacral Interbody Fusion

The procedure for 1-level axial LIF is as follows1: Under fluoroscopic monitoring, a blunt guide pin introducer is passed through a 15-mm to 20-mm incision lateral to the coccyx and advanced along the midline of the anterior surface of the sacrum. A guide pin is introduced and tapped into the sacrum. A series of graduated dilators are advanced over the guide pin, and a dilator sheath attached to the last dilator is left in place to serve as a working channel for the passage of instruments. A cannulated drill is passed over the guide pin into the L5-S1 disc space to rest on the inferior endplate of L5. It is followed by cutters alternating with tissue extractors, and the nucleus pulposus is debulked under fluoroscopic guidance. Next, bone graft material is injected to fill the disc space. The threaded rod is placed over the guide pin and advanced through the sacrum into L5. The implant is designed to distract the vertebral bodies and restore disc and neural foramen height. The additional graft material is injected into the rod, where it enters into the disc space through holes in the axial rod. A rod plug is then inserted to fill the cannulation of the axial rod. Percutaneous placement of pedicle or facet screws may be used to provide supplemental fixation.

An advantage of axial LIF is that it allows preservation of the annulus and all paraspinous soft tissue structures. However, there is an increased need for fluoroscopy and an inability to address intracanal pathology or visualize the discectomy procedure directly. Complications of the axial approach may include perforation of the bowel and injury to blood vessels and/or nerves.

Summary of Evidence

For individuals with degenerative spine disease at the L4- S1 disc spaces who receive axial LIF the evidence includes comparative systematic review of case series and a retrospective comparative study. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The systematic review found that fusion rates were higher following transforaminal LIF than following axial LIF, although this difference decreased with use of bone morphogenetic protein or pedicle screws. The findings of this systematic review were limited by the lack of prospective comparative studies and differences in how fusion rates were determined. Studies suggest that complication rates may also be increased with 2-level axial LIF. Controlled trials with clinical outcome measures are needed to better define the benefits and risks of this procedure compared with treatment alternatives. The evidence is insufficient to determine the effects of the technology on health outcomes.


Clinical Input Received from Physician Specialty Societies and Academic Medical Centers

While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted. In response to requests, input was received from 2 specialty medical societies and 3 academic medical centers while this policy was under review in 2011. The input considered axial LIF to be investigational.

Practice Guidelines and Position Statements

North American Spine Society
The North American Spine Society published guidelines on the treatment of degenerative spondylolisthesis in 2014.12 The Society gave a grade B recommendation for surgical decompression with fusion in patients with spinal stenosis and spondylolisthesis. The guideline discussed posterolateral fusion, 360° fusion, and minimally invasive fusion; it did not address axial lumbosacral interbody fusion.

American Association of Neurological Surgeons

The American Association of Neurological Surgeons published guidelines for interbody techniques for lumbar fusion in 2005 (part 11).13 There was insufficient evidence to recommend a treatment standard. Minimally invasive procedures were not reviewed.

National Institute for Health and Clinical Excellence

The National Institute for Health and Clinical Excellence provided guidance on transaxial interbody fusion in the lumbar spine in 2011.14 The guidance stated that current evidence on the efficacy of transaxial interbody lumbosacral fusion is “limited in quantity but shows symptom relief in the short term in some patients. Evidence on safety shows that there is a risk of rectal perforation.” The Institute encouraged “further research into transaxial interbody lumbosacral fusion. Research outcomes should include fusion rates, pain and functional scores, quality-of-life measures, and the frequency of both early and late complications.”