CAM 70128

Selective Posterior Rhizotomy for the Spasticity of Cerebral Palsy

Category:Surgery   Last Reviewed:March 2020
Department(s):Medical Affairs   Next Review:March 2999
Original Date:March 1996    

Description:
Spastic cerebral palsy is the most common form of cerebral palsy. It is manifested as hyperactive tendon reflexes, muscle hypertonia and increased resistance to increasing velocity of muscle stretch. Spastic cerebral palsy is further defined according to the affected limbs: Spastic hemiplegia involves the arm and leg on one side; spastic diplegia is characterized by lower extremity involvement primarily or exclusively; and spastic quadriplegia affects both arms and legs equally. Spastic diplegia is the most common type. When involving the lower extremities, the hypertonia induced by spasticity prevents normal standing, walking or crawling.

Selective posterior (dorsal) rhizotomy is a surgical procedure that is intended to reduce spasticity by diminishing the number of afferent nerve transmissions to neuronal circuits that regulate the spinal stretch reflex. Either cervical or lumbar laminectomy is used to expose the appropriate spinal nerves. Either a predetermined percentage of the dorsal rootlets are severed or electromyographic responses to direct electrical stimulation may be used to identify specific nerve roots involved in spasticity-producing circuits. Selective posterior rhizotomy has been offered to patients in an attempt to increase ambulation, and in a smaller subset of patients without ambulatory potential, but whose severe spasticity limits adequate care and handling.

Policy:
Selective dorsal rhizotomy may be considered MEDICALLY NECESSARY in the treatment of persons with cerebral palsy and associated severe spasticity interfering with gross motor function or adequate care.

Policy Guidelines:
In general, dorsal rhizotomy should be limited to those patients who retain some ambulatory potential and to a smaller subset of patients without ambulatory potential, but whose severe spasticity limits adequate care.

Benefit Application
BlueCard®/National Account Issues
Intensive outpatient physiotherapy for 3 to 6 months is typically offered as part of the postoperative treatment of patients. Benefits for physical therapy may be subject to contractual limitations.  

Rationale
A randomized clinical trial comparing posterior rhizotomy plus physiotherapy compared to physiotherapy alone has reported improved results among those treated surgically, suggesting that the improvement in motor function after surgery is more than can be explained by physiotherapy alone. (1) These results are consistent with the results of the many case series that have been reported over the years. (2,3) Methods of targeting which dorsal rootlets to sever are still evolving, with fewer and fewer rootlets being cut as experience is gained. Further study is needed to determine if selection of nerve rootlets for rhizotomy on the basis of patient responses to intraoperative electrical stimulation is any better than performing predetermined partial posterior rhizotomies. (4)

References:

  1. Steinbok P, Reiner AM, Beauchamp R et al. A randomized clinical trial to compare selective posterior rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegic cerebral palsy. Dev Med Child Neurol 1997; 39(3):178-84.
  2. Peacock WJ, Staudt LA. Functional outcomes following selective posterior rhizotomy in children with cerebral palsy. J Neurosurg 1991; 74(3):380-5.
  3. Chicoine MR, Park TS, Kaufman BA. Selective dorsal rhizotomy and rates of orthopedic surgery in children with spastic cerebral palsy. J Neurosurg 1997; 86(1):34-9.
  4. Steinbok P, Gustavsson B, Kestle JR et al. Relationship of intraoperative electrophysiological criteria to outcome after selective functional posterior rhizotomy. J Neurosurg 1995;83(1):18-26.

Coding Section

Codes Number Description
CPT 63185-63190 Rhizotomy code range
  95860-95869 Electromyography (EMG) code range
ICD-9 Procedure 03.1 Division of intraspinal nerve root
  93.08 Electromyography
ICD-9 Diagnosis 343.0-343.9 Infantile cerebral palsy code range
HCPCS No code  
ICD-10-CM (effective 10/01/15)  G800  Spastic quadriplegic cerebral palsy
  G801  Spastic diplegic cerebral palsy
  G802  Spastic hemiplegic cerebral palsy
  G808  Other cerebral palsy
  G809  Cerebral palsy, unspecified
ICD-10-PCS (effective 10/01/15)  01810ZZ  Division of Cervical Nerve, Open Approach
  01813ZZ  Division of Cervical Nerve, Percutaneous Approach
  01814ZZ  Division of Cervical Nerve, Percutaneous Endoscopic Approach
  01880ZZ  Division of Thoracic Nerve, Open Approach
  01883ZZ  Division of Thoracic Nerve, Percutaneous Approach
  01884ZZ  Division of Thoracic Nerve, Percutaneous Endoscopic Approach
  018B0ZZ  Division of Lumbar Nerve, Open Approach
  018B3ZZ  Division of Lumbar Nerve, Percutaneous Approach
  018B4ZZ  Division of Lumbar Nerve, Percutaneous Endoscopic Approach
  018R0ZZ  Division of Sacral Nerve, Open Approach
  018R3ZZ  Division of Sacral Nerve, Percutaneous Approach
  018R4ZZ  Division of Sacral Nerve, Percutaneous Endoscopic Approach
  4A0F33Z  Measurement of Musculoskeletal Contractility, Percutaneous Approach
  4A0FX3Z  Measurement of Musculoskeletal Contractility, External Approach
Type of Service Surgery  
Place of Service Inpatient  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

03/02/2020 

Annual review. No change to policy intent. 

03/04/2019 

Annual review, no change to policy intent. 

03/19/2018 

Annual Review. No change to policy intent 

03/01/2017 

Annual review.  No change to policy intent 

03/09/2016 

Annual review. No change to policy intent. 

09/23/2015 

Added ICD-10 codes to policy. 

03/05/2015 

Annual review. No change to policy intent. Added coding. 

03/3/2014

Annual review. No changes made.


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