LCD Reference Article Response To Comments Article

Response to Comments: Cervical Fusion

A59738

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Source Article ID
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Article ID
A59738
Original ICD-9 Article ID
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Article Title
Response to Comments: Cervical Fusion
Article Type
Response to Comments
Original Effective Date
05/23/2024
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This article address comment received by Noridian Healthcare Solutions, CGS Administrators, National Government Services, Palmetto GBA, WPS Government Health Administrators, First Coast Service Options and Novitas Solutions during the open comment period for this policy.

Response To Comments

Number Comment Response
1

A comment was received from a physician/medical director. He states:

  1. “Myelopathy is not caused by cervical nerve root impingement. If myelopathy is present, then the exception to conservative therapy requirements in Section B for symptomatic cervical canal stenosis would suffice.” He recommends removing Myelopathy class III or above from the exceptions to conservative therapy for decompression of symptomatic cervical nerve root impingement section.

2. Cauda equine syndrome is not possible in relation to the cervical spine; it is a lumbar spine condition and has no place in a cervical spine fusion LCD. I would recommend removal of cauda equina syndrome. 

Thank you for your comments. We agree nerve root impingement does not cause myelopathy; however, it may be associated with cervical myelopathy or myeloradiculopathy. The wording has been adjusted in the LCD to clarify this. We also agree that cauda equina is rare below L1 and above the thoracic spine, however, it can occur at any level of the spinal cord as lumbar and sacral nerve roots go through the cervical canal- to clarify this distinction cauda equina was replaced with loss of bowel or bladder function due to cervical spinal cord compression in the LCD.  

2

The Medical Advisory Group of ChiroCongress submitted comments and a white paper. They state that in development of the CAC they appreciate the effort to include wide array of providers and the addition of physical therapy to the panel, but felt we omitted the potential contribution from chiropractors.

Thank you for your comments. Your point is well received and we will consider the addition of Doctor of Chiropractic to future panel of experts. 

3

A chiropractor submitted a recent review on the role of chiropractic care for disc herniation and cervical radiculopathy prior to consideration of cervical fusion. He requests spinal manipulation (Chiropractic therapy) be added to the list of conservative treatment to be tried prior to cervical fusion.

Another chiropractor who is a CAC member for WPS sent a letter to express support for the inclusion of spinal manipulation as one of the conservative options prior to proceeding with cervical fusion with the Clinical Compass White paper as evidence of potential benefit.

Thank you for your comments. Spinal manipulation is included under the list of conservative treatments to be utilized prior to proceeding with cervical fusion. See the definition of conservative therapy within the LCD. We list all potential interventions and do not require specific ones due to lack of comparative studies on these options. 

4

HCA Regulatory Compliance Support request clarification of Under Limitations, for item 1 in the section “Exceptions to conservative therapy requirement for decompression of symptomatic cervical nerve root impingement:”, which scale is being referenced in relation to “Cervical myelopathy class III or above”.

For Indication C.4. “Deformities that include the cervical spine including when3:”, the last criteria should be revised to “OR progression of deformity” rather than “AND progression of deformity”. Research published via the ISSG has demonstrated severe disability associated with cervical deformities regardless of deformity progression. Attached are published references showing threshold values for pain and disability for cervical deformity which delineates that one does not need to have deformity progression for pain and disability, the deformity alone can cause pain and disability without progression. Two articles were submitted.

Thank you for your comments. The classification system described by Ranawat can be found in the Evidence Section of the LCD under “Cervical Myeloradiculopathy (Mixed).” Based on the submitted literature we agree there may be a role for correction of cervical deformity in the presence of pain and disability without deformity progression; therefore the “AND” has been changed to “OR.” 

5

A comment was received that the limitation of asymptomatic myelopathy (regardless of severity on imagining findings) as not reasonable and necessary should be removed. The commenter states there are situations when a clinically significant, even if asymptomatic) myelopathy may require surgical intervention and should be left to provider discretion. 

Thank you for your comments. There was not literature to support a role for surgical intervention in this population. If there is literature to expand to this group it can be submitted through the LCD reconsideration process. 

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L39741 - Cervical Fusion
Related National Coverage Documents
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