|Original Policy Date
|Last Review Status/Date
Reviewed by consensus/3:2003
|Return to Medical Policy Index|
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.
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.
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.
No applicable information
No applicable information
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.
TEC Evaluation and Coverage 1990: p. 3
Technology Evaluation and Coverage 1988: p. 134
|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|
|Type of Service||Surgery|
|Place of Service||Inpatient
|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|