Utilization Review Checklist
Cervical Radiculopathy from Herniated Disc
Derived from the ACOEM Cervical and Thoracic Spine Disorders Guideline, edition 17 October 2018, as adopted into the California MTUS 18 April 2019. CPT 63020, 63075, 22551, 22554, 22856, 63045. ICD-10 M50.10, M50.11, M50.12, M50.13, M54.12, M54.13.
Draft — not reviewed or approved by COA. Prepared by Rette from the ACOEM guideline named above. This is not a COA document and does not reproduce COA’s own checklists.
CriteriaCheck if documented
Presumptive Diagnosis
Any one of the following
Current dermatomal pain and/or numbness consistent with radiculopathy from a herniated disc
“radicular pain syndrome with current dermatomal pain and/or numbness, or myotomal muscle weakness, or ongoing denervation changes by needle EMG consistent with radiculopathy from a herniated disc” — p. 106
OR
Myotomal muscle weakness consistent with radiculopathy from a herniated disc
“or myotomal muscle weakness, or ongoing denervation changes by needle EMG consistent with radiculopathy from a herniated disc” — p. 106
OR
Ongoing denervation changes by needle EMG consistent with radiculopathy from a herniated disc
“or ongoing denervation changes by needle EMG consistent with radiculopathy from a herniated disc” — p. 106
Confirmatory Diagnosis
Required
MRI, or CT with or without myelography, confirming persisting nerve root compression at the level and on the side predicted by the history and clinical examination
“imaging findings by MRI, or CT with or without myelography, that confirm persisting nerve root compression at the level and on the side predicted by the history and clinical examination” — p. 106
Conservative Care
Any one of the following
Continued significant pain and functional limitation after at least 6 weeks of time and appropriate non-operative treatment — at least 6 weeks
“continued significant pain and functional limitation after at least 6 weeks of time and appropriate non-operative treatment” — p. 106
OR
Objective evidence of a progressive neurological deficit or myelopathy
“unless objective evidence of a progressive neurological deficit or myelopathy is present.” — p. 106
Procedures — the guideline treats each separately
Cervical discectomy for subacute or chronic radiculopathy — open, microdiscectomy or endoscopic
Recommended. Cervical discectomy is recommended to speed recovery in patients with subacute or chronic radiculopathy due to ongoing nerve root compression
Strength of Evidence — Recommended, Evidence (C) · confidence high · p. 106
Indications — required:
All three indications are documented, including the non-operative treatment period
“Indications – All of the following present:” — p. 106
The guideline leaves the choice of open, micro or endoscopic technique, and of anterior versus posterior approach, to the surgeon and patient. Do not argue technique; document the three indications and the duration.
Cervical discectomy with fusion for chronic radiculopathy
Recommended. Cervical discectomy with fusion is recommended for patients with chronic radiculopathy due to ongoing nerve root compression who continue to have significant pain and functional limitation after at least 6 months of time and appropriate non-operative treatment.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate · p. 110
Indications — required:
Continued significant pain and functional limitation after at least 6 months of time and appropriate non-operative treatment — at least 6 months
“Cervical discectomy with fusion is recommended for patients with chronic radiculopathy due to ongoing nerve root compression who continue to have significant pain and functional limitation after at least 6 months of time and appropriate non-operative treatment.” — p. 110
Recommended for chronic radiculopathy. The guideline notes the fusion technique is the surgeon's and patient's choice.
Cervical disc replacement for subacute or chronic radiculopathy or myelopathy
Moderately Recommended. Disc Replacement for Subacute or Chronic Cervical Radiculopathy or Myelopathy
Strength of Evidence — Moderately Recommended, Evidence (B) · confidence moderate · p. 113
Indications — required:
Subacute or chronic cervical radiculopathy or myelopathy is documented
“Disc Replacement for Subacute or Chronic Cervical Radiculopathy or Myelopathy” — p. 113
Moderately Recommended on Evidence (B) — notably STRONGER support than the cervical chapter gives fusion, and the opposite of the Low Back chapter's position on lumbar disc replacement, where the same procedure gets No Recommendation. Do not carry a lumbar assumption across.
Spinal fusion performed with simultaneous discectomy
Recommended. Spinal Fusion with Simultaneous Discectomy
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low · p. 110
Indications — required:
Fusion is being performed at the same time as a discectomy that meets its own indications
“Spinal Fusion with Simultaneous Discectomy” — p. 110
Recommended as an option, on Insufficient Evidence at Low confidence.
Cervical discectomy for acute radiculopathy (under 4 weeks' duration)
Not Recommended. Cervical discectomy is not recommended for acute radiculopathy (under 4 week's duration) unless objective evidence of a progressive neurological deficit or myelopathy is present.
Strength of Evidence — Not Recommended, Insuffcient Evidence (I) · confidence moderate · p. 106
Indications — required:
Objective evidence of a progressive neurological deficit or myelopathy — the only exception the guideline allows in the acute window
“unless objective evidence of a progressive neurological deficit or myelopathy is present.” — p. 106
Not recommended UNLESS there is objective evidence of a progressive neurological deficit or myelopathy. If either is present, document it objectively and on serial examinations — the guideline requires sufficient time for natural resolution otherwise.
Discectomy for cervical or thoracic spine pain WITHOUT radiculopathy
Not Recommended. Discectomy is not recommended for treatment of acute, subacute, or chronic cervical pain or thoracic pain without radiculopathy.
Strength of Evidence — Not Recommended, Insuffcient Evidence (I) · confidence high · p. 106
Indications — required:
The guideline advises against discectomy where there is no radiculopathy, at High confidence
“Discectomy is not recommended for treatment of acute, subacute, or chronic cervical pain or thoracic pain without radiculopathy.” — p. 106
Not recommended at High confidence, for acute, subacute or chronic pain alike.
Percutaneous discectomy (nucleoplasty), laser discectomy or disc coblation
Not Recommended. Percutaneous discectomy (nucleoplasty), laser discectomy, and disc coblation therapy are not recommended as treatment for any spine or radicular pain syndrome.
Strength of Evidence — Not Recommended, Insuffcient Evidence (I) · confidence low · p. 106
Indications — required:
The guideline advises against these for any spine or radicular pain syndrome
“Percutaneous discectomy (nucleoplasty), laser discectomy, and disc coblation therapy are not recommended as treatment for any spine or radicular pain syndrome.” — p. 106
Not recommended as treatment for ANY spine or radicular pain syndrome.
Cervical disc replacement for chronic non-specific cervical pain
Not Recommended. Disc Replacement for Chronic Non-specific Cervical Pain
Strength of Evidence — Not Recommended, Insuffcient Evidence (I) · confidence moderate · p. 113
Indications — required:
The guideline advises against disc replacement where the cervical pain is non-specific
“Disc Replacement for Chronic Non-specific Cervical Pain” — p. 113
Not recommended where the pain is non-specific. Radiculopathy or myelopathy is what moves this into the supported path.