PILD for LSS Remains Non-covered Under Medicare
In a decision memo released Jan. 9, the Centers for Medicare & Medicaid Services (CMS) announced its national coverage determination for percutaneous image-guided lumbar decompression (PILD) for lumbar spinal stenosis (LSS). PILD for LSS remains a non-covered service for Medicare beneficiaries. However, CMS will cover the procedure for Medicare patients with LSS when performed in a clinical study through coverage of evidence development (CED).
“While there is limited evidence on the treatment of LSS with PILD, LSS is prevalent in the Medicare population, and we believe that CED studies have potential to answer important questions about this treatment for our beneficiaries,” CMS said in the decision memo.
The PILD Procedure
PILD is a posterior decompression of the lumbar spine, used as treatment for symptomatic LSS unresponsive to conservative therapy. Generally considered a non-invasive procedure, PILD requires the use of specially designed instruments and X-ray guidance to percutaneously remove a portion of the lamina and debulk the ligamentum.
An LSS Diagnosis
According to Spine-Health, there are two types of spinal stenosis:
- Lumbar stenosis: When the spinal nerve roots in the lower back are compressed, or choked, causing symptoms of sciatica (tingling, weakness, or numbness that radiates from the low back and into the buttocks and legs).
- Cervical spinal stenosis: A narrowing of the spinal canal in the neck can lead to more serious symptoms, including major body weakness or even paralysis.
ICD-9-CM coding for lumbar stenosis is 724.02 Spinal stenosis, lumbar region, without neurogenic claudication or 724.03 Spinal stenosis, lumbar region, with neurogenic claudcation. ICD-9-CM coding for cervical spinal stenosis is 723.0 Spinal stenosis in cervical region.
ICD-10 coding for lumbar stenosis is M48.06 Spinal stenosis, lumbar region. ICD-10 coding for cervical spinal stenosis is M48.02 Spinal stenosis, cervical region.
CMS received 201 comments on the proposed decision memo, released Oct. 17, 2013. Of those, 195 comments advocated Medicare coverage of PILD for LSS—most of which were from physicians who perform PILD. Six comments were from physician organizations: The American Society of Anesthesiologists, the American Academy of Pain Medicine, and the American Society of Interventional Pain Physicians all advocated for PILD coverage. The North American Spine Society advocated for coverage under CED; and the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, and the AANS/CNS Joint Section on disorders of the Spine and Peripheral Nerves submitted a united comment advocating for non-coverage. Likewise, the America’s Health Insurance Plans advocated for non-coverage.
A number of the comments advocated PILD for LSS on the basis that CMS had already deemed the procedure reasonable and necessary when it determined that CPT® code 0275T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar met the criteria under section 416.166 of the Social Security Act to be safely performed in the ambulatory surgery center setting.
CMS’ responded, stating, “Coding and payment classifications are not coverage determinations. Moreover, the ability to submit a claim for furnishing a procedure in any particular setting is not a guarantee that the procedure is clinically beneficial for the patient or that Medicare will pay the claim.”
See CAG-00433N for complete details of the analysis and for CED guidelines.