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MP 7.01.32 Chemonucleolysis

Medical Policy
Section
Surgery
Original Policy Date
3/31/96
Last Review Status/Date
Reviewed by consensus/3:2003
Issue
3:2003
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

Chemonucleolysis entails the injection of the enzymatic chymopapain into a disc for the treatment of intervertebral disc disease. A local anesthetic supplemented by intravenous sedation is administered. The needle is then inserted into the nucleus pulposus by lateral approach. The needle is kept in place for five minutes as chymopapain is injected very slowly into the disc.


Policy

Chemonucleolysis using chymopapain is considered medically necessary in patients with physical and diagnostic imaging evidence of an uncomplicated herniation of a single lumbar disc with no evidence of a free fragment or sequestration of a portion of a disc. Chemonucleolysis using chymopapain is considered not medically necessary in patients who demonstrate any of the following:

  • known or suspected allergy to papaya extracts, including chymopapain and related chemicals;
  • a history of previous chemonucleolysis by chymopapain injection;
  • prior surgical treatment on the disc presently suspected to harbor a symptomatic herniation;
  • progressive neurologic dysfunction;
  • impairment of bowel or bladder function;
  • evidence of a sequestered disc or free fragment of disc; or
  • evidence of vertebral disease such as spinal stenosis or spondylolisthesis.

Chemonucleolysis is considered investigational for use in the cervical and thoracic disc regions.


Policy Guidelines

No applicable information


Benefit Application

No applicable information


Rationale

A search of literature was completed through the MEDLINE database for the period of January 1992 through October 1995. The search strategy focused on references containing the following Medical Subject Heading:

– Intervertebral Disc Chemolysis

Research was limited to English-language journals on humans.

See also:

TEC Evaluation and Coverage 1990: p. 3
 
Technology Evaluation and Coverage 1988: p. 134

 

Codes

Number

Description

CPT  62292  Injection procedure for chemonucleolysis including discography, intervertebral disc, single or multiple levels, lumbar 
ICD-9 Procedure  80.52  Intervertebral chemonucleolysis 
ICD-9 Diagnosis  722.10  Displacement of lumbar intervertebral disc without myelopathy 
HCPCS  No code 
Type of Service  Surgery 
Place of Service  Inpatient
 
Outpatient
 


Index

Chemonucleolysis
Chymopapain


Policy History

Date Action Reason
03/31/96 Add to Surgery section New policy
04/15/02 Replace policy Policy reviewed without literature review; new review date only
10/9/03 Replace policy Policy reviewed by consensus without literature review; no changes in policy; no further review scheduled


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