Reimbursement Policy Lumbar Artificial Disc Replacement (LADR) (NCD 150.10)

Reimbursement Policy

Lumbar Artificial Disc Replacement (LADR) (NCD 150.10)

Policy 150.10 Number

Approved UnitedHealthcare Medicare By Reimbursement Policy Committee

Current 01/22/2014 Approval Date

IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY

This policy is applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates.

You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare reimbursement policies use Current Procedural Terminology (CPT?*), Centers for Medicare and Medicaid Services (CMS), or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement.

This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms (CMS 1450). Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy.

This information is intended to serve only as a general resource regarding UnitedHealthcare's reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare enrollees. Other factors affecting reimbursement may supplement, modify or, in some cases, supersede this policy. These factors may include, but are not limited to: legislative mandates, the physician or other provider contracts, and/or the enrollee's benefit coverage documents. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare due to programming or other constraints; however, UnitedHealthcare strives to minimize these variations.

UnitedHealthcare may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication.

*CPT copyright 2010 (or such other date of publication of CPT) American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc.

Table of Contents Application ......................................................................................................................................2 Summary .........................................................................................................................................2

Overview........................................................................................................................................2 Reimbursement Guidelines ...............................................................................................................2 CPT/HCPCS Codes ...........................................................................................................................2 Modifiers .........................................................................................................................................3 ICP/PCS Codes................................................................................................................................3 References Included (but not limited to): .......................................................................................3 CMS NCD .......................................................................................................................................3 CMS LCD(s) ....................................................................................................................................3 CMS Article(s).................................................................................................................................4 CMS Claims Processing Manual .........................................................................................................4 CMS Transmittals ............................................................................................................................4 UnitedHealthcare Medicare Advantage Coverage Summaries ................................................................4 UnitedHealthcare Reimbursement Policies ..........................................................................................4 UnitedHealthcare Medical Policies ......................................................................................................4 MLN Matters ...................................................................................................................................4 Others ...........................................................................................................................................4 History ............................................................................................................................................4

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Reimbursement Policy

Lumbar Artificial Disc Replacement (LADR) (NCD 150.10)

Application

This reimbursement policy applies to services reported using the Health Insurance Claim Form CMS-1500 or its electronic equivalent or its successor form, and services reported using facility claim form CMS-1450 or its

electronic equivalent or its successor form. This policy applies to all products, all network and non-network physicians, and other health care professionals. The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing UnitedHealthcare. It is not enough to link the procedure code to a correct, payable ICD-9-CM diagnosis code. The diagnosis must be present for the procedure to be paid. Compliance with the provisions in this policy is subject to monitoring by pre-payment review and/or post-payment data analysis and subsequent medical review. The effective date of changes/additions/deletions to this policy is the committee meeting date unless otherwise indicated. CPT codes and descriptions are copyright 2010 American Medical Association (or such other date of publication of CPT). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS restrictions apply to Government use. Fee schedules, relative value units, conversion factors, and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Current Dental Terminology (CDT), including procedure codes, nomenclature, descriptors, and other data contained therein, is copyright by the American Dental Association, 2002, 2004. All rights reserved. CDT is a registered trademark of the American Dental Association. Applicable FARS/DFARS apply.

Summary

Overview The LADR is a surgical procedure on the lumbar spine that involves complete removal of the damaged or diseased lumbar intervertebral disc and implantation of an artificial disc. The procedure may be done as an alternative to lumbar spinal fusion and is intended to reduce pain, increase movement at the site of surgery and restore intervertebral disc height. The FDA has approved the use of the lumbar artificial disc for spine arthroplasty in skeletally mature patients with degenerative or discogenic disc disease at one level for L3 to S1.

Reimbursement Guidelines Effective for services performed from May 16, 2006 through August 13, 2007, LADR with the Charite TM lumbar artificial disc is non-covered for Medicare beneficiaries over 60 years of age. Effective for services performed on or after August 14, 2007, CMS has found that LADR is not reasonable and necessary; therefore, LADR is non-covered for Medicare beneficiaries over 60 years of age. For Medicare beneficiaries 60 years of age and younger, there is no national coverage determination for LADR, leaving such determinations to continue to be made by the local contractors. For dates of service May 16, 2006 through August 13, 2007, Medicare coverage under the investigational device exemption (IDE) for LADR with a disc other than the Charite TM lumbar disc in eligible clinical trials is not impacted. (This NCD last reviewed August 2007.)

CPT/HCPCS Codes

Code

Description

22857

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar

22862

Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar

22865

Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar

0163T

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional interspace, lumbar

0164T

Removal of total disc arthroplasty, (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure)

0165T

Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar

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Reimbursement Policy

Lumbar Artificial Disc Replacement (LADR) (NCD 150.10)

Modifiers Code GZ

Description Item or service expected to be denied as not reasonable and necessary

ICP/PCS Codes

ICP Code

Description

84.64

Insertion of partial spinal disc prosthesis, lumbosacral

PCS Code 0SR20JZ

Description

Replacement of lumbar vertebral disc with synthetic substitute, open approach

0SR40JZ

Replacement of lumbarsacral disc with synthetic substitute, open approach

84.65

Insertion of total spinal disc prosthesis, lumbosacral

0SR20JZ

Replacement of lumbar vertebral disc with synthetic substitute, open approach

0SR40JZ

Replacement of lumbarsacral disc with synthetic substitute, open approach

84.68

Revision or replacement of artificial spinal disc prosthesis, lumbosacral

0SW20JZ

Revision of Synthetic Substitute in Lumbar Vertebral Disc, Open Approach

0SW23JZ

Revision of Synthetic Substitute in Lumbar Vertebral Disc, Percutaneous Approach

0SW24JZ

Revision of Synthetic Substitute in Lumbar Vertebral Disc, Percutaneous Endoscopic Approach

0SW40JZ

Revision of Synthetic Substitute in Lumbosacral Disc, Open Approach

0SW43JZ

Revision of Synthetic Substitute in Lumbosacral Disc, Percutaneous Approach

0SW44JZ

Revision of Synthetic Substitute in Lumbosacral Disc, Percutaneous Endoscopic Approach

0SP20JZ

Removal of Synthetic Substitute from Lumbar Vertebral Disc, Open Approach

0SR20JZ

Replacement of Lumbar Vertebral Disc with Synthetic Substitute, Open Approach

0SP40JZ

Removal of Synthetic Substitute from Lumbosacral Disc, Open Approach

0SR40JZ

Replacement of Lumbosacral Disc with Synthetic Substitute, Open Approach

References Included (but not limited to): CMS NCD NCD 150.10 Lumbar Artificial Disc Replacement (LADR) CMS LCD(s) Numerous LCDs

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Reimbursement Policy

Lumbar Artificial Disc Replacement (LADR) (NCD 150.10)

CMS Article(s) Numerous Articles CMS Claims Processing Manual Chapter 32, ? 170.1 and ? 170.2 Billing Requirements for Lumbar Artificial Disc Replacement CMS Transmittals Transmittal 75, Change Request 5727, Dated 09/11/2007, (Lumbar Artificial Disc Replacement) (LADR)) Transmittal 1199, Change Request 8197, Dated 03/15/2013, (International Classification of Diseases (ICD)-10 Conversion from ICD-9 and Related Code Infrastructure of the Medicare Shared Systems as They Relate to CMS National Coverage Determinations (NCDs)) Transmittal 1340, Change Request 5727, Dated 09/21/2007 (Lumbar Artificial Disc Replacement (LADR)) Transmittal 2636, Change Request 7501, Dated 12/19/1996 (National Correct Coding Initiative (NCCI) Add-On Codes Replacement of Identical Letter, Correct Coding Initiative Add-On (ZZZ) Codes) UnitedHealthcare Medicare Advantage Coverage Summaries Artificial Disc Replacement, Cervical and Lumbar (LADR) UnitedHealthcare Reimbursement Policies Bone (Mineral) Density Studies (NCD 150.3) Category III CPT Codes Microsurgery UnitedHealthcare Medical Policies Total Artificial Disc Replacement for the Spine Surgical Treatment for Spine Pain MLN Matters Article MM8197, International Classification of Diseases (ICD)-10 Conversion from ICD-9 and Related Code Infrastructure of the Medicare Shared Systems as They Relate to CMS National Coverage Determinations (NCDs) Article MM5727, Lumbar Artificial Disc Replacement (LADR) Article MM5462, Coding Change for Lumbar Artificial Disc Replacement (LADR) Others Decision Memo for Lumbar Artificial Disc Replacement (LADR) (CAG-00292R), CMS Website Federal Register, Vol. 70, No. 85, Wednesday, May 4, 2005, Proposed Rules, CMS Website

History Date 09/09/2014

Revisions Removed liability modifier references

01/22/2014 ? Annual review ? Added 0164T, 84.64 and 84.68 to the code list as it is applicable to this NCD

03/13/2013 Annual review with no changes

09/14/2011 Administrative updates

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