National Coverage Determination (NCD) for

Surgical Decompression for Peripheral Polyneuropathy  -

RETIRED

Surgical Decompression for Peripheral Polyneuropathy is not considered reasonable and necessary for the diagnosis or treatment of an injury or disease.

Surgical Decompression for Peripheral Polyneuropathy (CPT codes 01470, 28035, 64702, 64704, 64708, 64712, 64714, 64722, 64726, 64727) is noted as a noncovered service.

 

Some of the emerging techniques and associated tools are considered investigational and this LCD does NOT endorse such procedure.

 

 •  NOTE: An Advance Beneficiary Notice (ABN) is required for items and services not covered by Medicare

     due to being considered not medically reasonable and necessary.

           ◦  The beneficiary should be thoroughly educated about the benefits and risks of this item or service.

           ◦  If such notice is not given, providers may not shift financial liability for such items or services to beneficiaries

              should a claim for such items or services be denied by Medicare.

Indications:

• At present, the preponderance of clinical evidence as noted in various publications in the peer-reviewed literature is

   NOT sufficient to support the efficacy of surgical decompression of peripheral nerves for the treatment of

   symptomatic diabetic metabolic, inflammatory or toxic polyneuropathy.

• Therefore, this Local Coverage Determination (LCD) finds surgical decompression of peripheral nerves as NOT

    reasonable and necessary and therefore not eligible for reimbursement by Medicare.

Discussion:

• AMA CPT Copyright Statement

• CPT codes, descriptions and other data only are copyright 2015 American Medical Association (or such other date

   of publication of CPT). All Rights Reserved.

CPT/HCPCS Codes:

• 01470 ANESTHESIA FOR PROCEDURES ON NERVES, MUSCLES, TENDONS, AND FASCIA OF LOWER LEG, ANKLE,

                AND FOOT; NOT OTHERWISE SPECIFIED

• 28035 RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION)

• 64702 NEUROPLASTY; DIGITAL, 1 OR BOTH, SAME DIGIT

• 64704 NEUROPLASTY; NERVE OF HAND OR FOOT

• 64708 NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED

• 64712 NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; SCIATIC NERVE

• 64714 NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; LUMBAR PLEXUS

• 64722 DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY)

• 64726 DECOMPRESSION; PLANTAR DIGITAL NERVE

• 64727 INTERNAL NEUROLYSIS, REQUIRING USE OF OPERATING MICROSCOPE (LIST SEPARATELY IN ADDITION TO

               CODE FOR NEUROPLASTY) (NEUROPLASTY INCLUDES EXTERNAL NEUROLYSIS)

ICD-10 CM Codes not covered for indications:

A52.15   Late syphilitic neuropathy

E08.40   Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified

E08.42   Diabetes mellitus due to underlying condition with diabetic polyneuropathy

E09.40   Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy,

                 unspecified

E09.42   Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy

E10.40   Type 1 diabetes mellitus with diabetic neuropathy, unspecified

E10.41   Type 1 diabetes mellitus with diabetic mononeuropathy

E10.42   Type 1 diabetes mellitus with diabetic polyneuropathy

E10.43   Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy

E10.44   Type 1 diabetes mellitus with diabetic amyotrophy

E10.49   Type 1 diabetes mellitus with other diabetic neurological complication

E10.610  Type 1 diabetes mellitus with diabetic neuropathic arthropathy

E10.65   Type 1 diabetes mellitus with hyperglycemia

E11.40   Type 2 diabetes mellitus with diabetic neuropathy, unspecified

E11.41   Type 2 diabetes mellitus with diabetic mononeuropathy

E11.42   Type 2 diabetes mellitus with diabetic polyneuropathy

E11.43   Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy

E11.44   Type 2 diabetes mellitus with diabetic amyotrophy

E11.49   Type 2 diabetes mellitus with other diabetic neurological complication

E11.610  Type 2 diabetes mellitus with diabetic neuropathic arthropathy

E13.40   Other specified diabetes mellitus with diabetic neuropathy, unspecified

E13.41   Other specified diabetes mellitus with diabetic mononeuropathy

E13.42   Other specified diabetes mellitus with diabetic polyneuropathy

E13.43   Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy

E13.44   Other specified diabetes mellitus with diabetic amyotrophy

E13.49   Other specified diabetes mellitus with other diabetic neurological complication

E13.610  Other specified diabetes mellitus with diabetic neuropathic arthropathy

G13.0   Paraneoplastic neuromyopathy and neuropathy

G13.1   Other systemic atrophy primarily affecting central nervous system in neoplastic disease

G58.7   Mononeuritis multiplex

G58.8   Other specified mononeuropathies

G58.9   Mononeuropathy, unspecified

G59   Mononeuropathy in diseases classified elsewhere

G60.0   Hereditary motor and sensory neuropathy

G60.1   Refsum's disease

G60.2   Neuropathy in association with hereditary ataxia

G60.3   Idiopathic progressive neuropathy

G60.3   Idiopathic progressive neuropathy

G60.8   Other hereditary and idiopathic neuropathies

G60.8   Other hereditary and idiopathic neuropathies

G60.9   Hereditary and idiopathic neuropathy, unspecified

G60.9   Hereditary and idiopathic neuropathy, unspecified

G61.0   Guillain-Barre syndrome

G61.1   Serum neuropathy

G61.1   Serum neuropathy

G61.81   Chronic inflammatory demyelinating polyneuritis

G61.81   Chronic inflammatory demyelinating polyneuritis

G61.89   Other inflammatory polyneuropathies

G61.9   Inflammatory polyneuropathy, unspecified

G62.0   Drug-induced polyneuropathy

G62.0   Drug-induced polyneuropathy

G62.1   Alcoholic polyneuropathy

G62.1   Alcoholic polyneuropathy

G62.2   Polyneuropathy due to other toxic agents

G62.2   Polyneuropathy due to other toxic agents

G62.81   Critical illness polyneuropathy

G62.82   Radiation-induced polyneuropathy

G62.82   Radiation-induced polyneuropathy

G62.89   Other specified polyneuropathies

G62.9   Polyneuropathy, unspecified

G63   Polyneuropathy in diseases classified elsewhere

G63   Polyneuropathy in diseases classified elsewhere

G64   Other disorders of peripheral nervous system

G65.0   Sequelae of Guillain-Barre syndrome

G65.1   Sequelae of other inflammatory polyneuropathy

G65.2  Sequelae of toxic polyneuropathy

M05.50   Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site

M05.511  Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder

M05.512  Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder

M05.519  Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified shoulder

M05.521  Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow

M05.522  Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow

M05.529  Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified elbow

M05.531  Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist

M05.532  Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist

M05.539  Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified wrist

M05.541  Rheumatoid polyneuropathy with rheumatoid arthritis of right hand

M05.542  Rheumatoid polyneuropathy with rheumatoid arthritis of left hand

M05.549  Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hand

M05.551  Rheumatoid polyneuropathy with rheumatoid arthritis of right hip

M05.552  Rheumatoid polyneuropathy with rheumatoid arthritis of left hip

M05.559  Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip

M05.561  Rheumatoid polyneuropathy with rheumatoid arthritis of right knee

M05.562  Rheumatoid polyneuropathy with rheumatoid arthritis of left knee

M05.569  Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee

M05.571  Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot

M05.572  Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot

M05.579  Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot

M05.59   Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites

M34.83   Systemic sclerosis with polyneuropathy

Treatment Logic:

• Peripheral polyneuropathy leads to damage of the nerves in the arms and legs, with the feet and legs usually

   affected before the hands and arms.

• Symptoms of peripheral neuropathy, which are often worse at night, may include:

• Numbness or insensitivity to pain or temperature.

• Tingling.

• Burning or prickling sensations.

• Sharp pains or cramps.

• Extreme sensitivity to touch.

• Loss of balance coordination.

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