# Mild



## brockorama01 (Aug 9, 2011)

I have a few pain physicians interested in performing the MILD procedure.  I am aware of the new Category III codes but I am looking to see if any ins carriers have any posted medical policies yet.

I have a patient in Florida who was recently told by a pain specialist that he had to try at least two other therapies before attempting the MILD.   I've search several Medicare and BC/BS carriers, but can find no LCD's or policies.  The procedure has had FDA approval for several years...has anyone seen medical policy on it?

Brock Berta
Billing Czar


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## aschaeve (Aug 9, 2011)

As of April of this year this is what was posted on the Anesthesia/Pain list serve; 

Just FYI.  Most of the insurance carriers we called consider this experimental and will not pay.  Cannot bill as laminectomy.  New code will soon be effective, but the procedure is still considered experimental by most carriers.

Hope this helps.

Alicia, CPC


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## dwaldman (Aug 11, 2011)

CPT Category III codes are not referred to the AMA-Specialty RVS Update Committee (RUC) for valuation because no relative value units (RVUs) are assigned to these codes. Payment for these services or procedures is based on the policies of payers and not on a yearly fee schedule.
In general, these codes are archived after five years if the code has not been accepted for placement in the Category I section of the CPT codebook, unless demonstrated that a Category III code is still needed. These codes will not be reused.

http://www.ama-assn.org/resources/doc/cpt/cptcat3codes.pdf


https://www.bcbskc.com/Public/Uploa..._Lumbar_Decompression_for_Spinal_Stenosis.pdf

Here excert of commercial carrier's medical policy for the procedure 
Summary
Posterior decompression for lumbar spinal stenosis has been evolving towards increasingly minimally invasive procedures in an attempt to minimize post-operative morbidity and spinal instability. In general, the literature comparing surgical procedures is limited. The evidence available suggests that less invasive surgical decompression may reduce perioperative morbidity without impairing long-term outcomes when performed in appropriately selected patients. In contrast to surgical decompression, the
mild® procedure is a percutaneous decompressive procedure performed solely under fluoroscopic guidance (e.g., without endoscopic or microscopic visualization of the work area). This procedure is indicated for central stenosis only, without the capability of addressing nerve root compression or disc herniation, should it be required. Due to the unknown impact of these limitations on health outcomes, randomized controlled studies in appropriate patients are needed to compare this novel procedure with the established alternatives. Although studies have been initiated, no evidence is available at this time
to evaluate the efficacy of image-guided percutaneous lumbar decompression. Therefore, this procedure is considered investigational.

Additionally from this link

http://www.painphysicianjournal.com/2010/january/2010;13;35-41.pdf

Conclusions: This review demonstrates the acute safety of the mild procedure with no
report of significant or unusual patient complications. To establish complication frequency
and longer-term safety profile associated with the treatment, additional studies are
currently being conducted. Survey data on file at Vertos Medical, Inc.


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## dwaldman (Aug 11, 2011)

Cigna's policy

http://www.cigna.com/customer_care/...criteria_invasive_treatment_for_back_pain.pdf

Aetna's policy

http://www.aetna.com/cpb/medical/data/1_99/0016.html

Unable to find UHC or Humana's policy.


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## brockorama01 (Aug 18, 2011)

Thanks.  Most helpful.

Although...wondering out loud...how can a clinic in Florida claim to have performed 200 of this over the last few years?  They went to each carrier (Medicare, BCBS, Cigna, etc) and argued medical necessity case by case?

Brock


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## dwaldman (Aug 18, 2011)

I believe it was possible, if the cases that were paying above average were making up for the ones that went to endless appeal status or adjustment.


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## dwaldman (Aug 19, 2011)

63030	Low back disk surgery	T	0208	51.3375	$3,535.92	
63005	Removal of spinal lamina	T	0208	51.3375	$3,535.92	
0275T	Perq lamot/lam lumbar	T	0208	51.3375	$3,535.92		
http://www.cms.gov/HospitalOutpatientPPS/AU/list.asp

It is interesting to note 0275T is in the same APC payment as code 63030 and 63005 so if there was some initial confusion about if a category 1 code could represent this before there was CPT Assistant clarification the facility payment still would be in line with what it should be and possibly meeting the "open or endoscopically-assited" reimbursement could be met on the physician side if that was considered as the compare code when is billed as 64999.

If performed on an Inpatient basis under 03.99, it would be in the same DRG as 03.09 or 80.51

DRG : 0491, BACK & NECK PROC EXC SPINAL FUSION W/O CC/MCC


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