Utilization Review Checklist
Thoracic 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 63064, 63066, 63077, 63078. ICD-10 M51.14, M51.15, M54.14, M54.15.
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
Required
Current dermatomal pain and/or numbness consistent with a herniated disc
“radicular pain syndrome with current dermatomal pain and/or numbness consistent with a herniated disc” — p. 107
Confirmatory Diagnosis
Required
MRI, or CT with or without myelography, confirming persisting nerve root compression at the predicted level and side
“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. 107
Conservative Care
Required
Continued significant pain and functional limitation after at least 3 months of time and appropriate non-operative treatment — at least 3 months
“continued significant pain and functional limitation after at least 3 months of time and appropriate non-operative treatment” — p. 107
Procedures — the guideline treats each separately
Thoracic discectomy for subacute or chronic radiculopathy
Recommended. Thoracic discectomy is recommended for treatment of patients with ongoing nerve root compression who continue to have significant pain and functional limitation after at least 3 months of time and appropriate non-operative therapy.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low · p. 107
Indications — required:
All three indications are documented
“Indications – All of the following present:” — p. 107
Recommended, but on Insufficient Evidence at Low confidence — the weakest support the chapter gives any recommended operation, because no quality studies exist. Document the three months carefully; it is the criterion most likely to be tested.