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Clinical Policy Bulletin:
Selective Peripheral Denervation (Bertrand Procedure) for Spasmodic Torticollis
Number: 0401


Policy

Aetna considers selective peripheral denervation (Bertrand procedure) medically necessary for the treatment of members with severe spasmodic torticollis (cervical dystonia) when both of the following criteria are met:

  • Current symptoms are disabling; and
  • Member has failed an appropriate course of pharmacotherapies or has had adverse side effects from the medications or the member has developed resistance to botulinum toxin type A or type B.

Aetna considers selective peripheral denervation experimental and investigational for the treatment of members with severe spasmodic torticollis when criteria are not met because the value of this procedure in persons without disability or in persons who have not failed medical management is unproven.

See also CPB 0113 - Botulinum Toxin.



Background

Spasmodic torticollis (cervical dystonia), or torticollis, is the most common of the focal dystonias.  It is a disorder in which neck muscles contract involuntarily, resulting in abnormal movements and posture of the head and neck.  In general, the term -- spasmodic torticollis (ST) -- is used to describe spasms in any direction: forward (anterocollis), backward (retrocollis), and sideway (torticollis).  The movement may be sustained or jerky.  Spasm in the muscles or pinching nerves in the neck can result in severe pain.  In this regard, cervical pain is seen in approximately 80 % of patients with ST.  Torticollis generally occurs in middle age; beginning slowly and usually reaching a plateau.  Approximately 10 to 20 % of individuals with this condition experience a spontaneous remission; however, the remission may not be permanent.

Since the cause of ST is unknown, there is currently no cure for this disorder.  Treatment is geared towards symptomatic relief.  Various medications are used in treating this condition.  Botox (botulinum toxin type A) injections have been demonstrated to improve both pain and head position in 70 to 80 % of patients with ST.  The toxin is injected into the 2 or 3 most functionally active muscles, most commonly the sternomastoid, spenius capitus or trapezius.

In very severe cases of disabling ST when pharmacotherapies including Botox injections have failed or the side effects are too severe, selective peripheral denervation may offer relief of symptoms.  Selective peripheral denervation is a procedure in which nerves are removed at the point where they enter the selected hyperactive muscles; while innervation to uninvolved muscles is maintained.  Studies have indicated that this procedure is useful in selected patients.  Positive response to prior botulinum toxin therapy appears to be a very good indicator of outcome following selective peripheral denervation.

A systematic evidence review of dystonias by the EFNS/MDS-ES Task Force (Albanese, et al., 2006) concluded: "Selective peripheral denervation is a safe procedure with infrequent and minimal side effects that is indicated exclusively in cervical dystonia. This procedure requires a specialized expertise."

Guidance from the National Institute for Clinical Excellence (2004) concluded:"Current evidence on the safety and efficacy of selective peripheral denervation for cervical dystonia appears adequate to support the use of this procedure provided that the normal arrangements are in place for consent, audit and clinical governance." The guidance stated that "patient selection for this procedure is important" and that "patients should be offered the procedure only when their disease has become refractory to best medical treatment." Standard medical treatments for cervical dystonia identified by NICE includes physiotherapy, drugs to reduce spasm, and injections of botulinum toxin. The NICE guidance said that selective peripheral denervation may be an alternative, especially for people who have not responded to other treatments.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
There is no specific code for Selective Peripheral Denervation (Bertrand Procedure) for Spasmodic Torticollis:
Other CPT codes related to the CPB:
64616
64640
Other HCPCS codes related to the CPB:
J0585 Botulinum toxin type A, per unit
J0587 Botulinum toxin type B, per 100 units
ICD-9 codes covered if selection criteria are met:
333.83 Spasmodic torticollis [severe, disabling]


The above policy is based on the following references:
  1. Hughes AJ. Botulinum toxin in clinical practice. Drugs. 1994;48(6):888-893.
  2. Davis DH, Ahlskog JE, Litchy WJ, Root LM. Selective peripheral denervation for torticollis: Preliminary results. Mayo Clin Proc. 1991;66(4):365-371.
  3. Bertrand CM. Selective peripheral denervation for spasmodic torticollis: Surgical techniques, results, and observations in 260 cases. Surg Neurol. 1994;40(2):96-103.
  4. Braun V, Richter HP. Selective peripheral denervation for the treatment of spasmodic torticollis. Neurosurgery. 1994;35(1):58-62.
  5. Braun V, Richter HP, Schroder JM. Selective peripheral denervation for spasmodic torticollis: Is the outcome predictable? J Neurol. 1995;242(8):504-507.
  6. Ford B, Louis ED, Greene P, Fahn S. Outcome of selective ramisectomy for botulinum toxin resistant torticollis. J Neurol Neurosurg Psychiatry. 1998;65(4):472-478.
  7. Munchau A, Palmer JD, Dressler D, et al. Prospective study of selective peripheral denervation for botulinum-toxin resistant patients with cervical dystonia. Brain. 2001;124(Pt 4):769-783.
  8. Braun V, Richter HP. Selective peripheral denervation for spasmodic torticollis: 13-year experience with 155 patients. J Neurosurg. 2002;97(2 Suppl):207-212.
  9. Dent THS. Selective denervation for spasmodic torticollis. Succinct and Timely Evaluated Evidence Review (STEER). Bazian, Ltd., eds. London, UK: Wessex Institute for Health Research and Development, University of Southampton; March 2002; 2(10). Available at: http://www.wihrd.soton.ac.uk/projx/signpost/steers/STEER_2002(10).pdf. Accessed December 9, 2002.
  10. Cohen-Gadol AA, Ahlskog JE, Matsumoto JY, et al. Selective peripheral denervation for the treatment of intractable spasmodic torticollis: Experience with 168 patients at the Mayo Clinic. J Neurosurg. 2003;98(6):1247-1254.
  11. National Institute for Clinical Excellence (NICE). Selective peripheral denervation for cervical dystonia. Interventional Procedure Guidance 80. London, UK: NICE; August 2004. Available at: http://guidance.nice.org.uk/IPG80/guidance/pdf/English. Accessed May 17, 2007.
  12. Othee GS, Menckhoff GR. Torticollis. eMedicine Orthopedic Surgery Topic 452. Omaha, NE: eMedicine.com; updated June 30, 2004. Available at: http://www.emedicine.com/orthoped/topic452.htm. Accessed: June 17, 2005.
  13. Loher TJ, Pohle T, Krauss JK. Functional stereotactic surgery for treatment of cervical dystonia: Review of the experience from the lesional era. Stereotact Funct Neurosurg. 2004;82(1):1-13.
  14. Taira T, Ochiai T, Goto S, Hori T. Multimodal neurosurgical strategies for the management of dystonias. Acta Neurochir Suppl. 2006;99:29-31.
  15. Albanese A, Barnes MP, Bhatia KP, et al. A systematic review on the diagnosis and treatment of primary (idiopathic) dystonia and dystonia plus syndromes: Report of an EFNS/MDS-ES Task Force. Eur J Neurol. 2006;13(5):433-444.
  16. Ferreira JJ, Costa J, Coelho M, Sampaio C. The management of cervical dystonia. Expert Opin Pharmacother. 2007;8(2):129-140.
  17. Anderson WS, Lawson HC, Belzberg AJ, Lenz FA. Selective denervation of the levator scapulae muscle: An amendment to the Bertrand procedure for the treatment of spasmodic torticollis. J Neurosurg. 2008;108(4):757-763.
  18. Huh R, Han IB, Chung M, Chung S. Comparison of treatment results between selective peripheral denervation and deep brain stimulation in patients with cervical dystonia. Stereotact Funct Neurosurg. 2010;88(4):234-238.
  19. Contarino MF, Van Den Munckhof P, Tijssen MA, et al. Selective peripheral denervation: Comparison with pallidal stimulation and literature review. J Neurol. 2014;261(2):300-308.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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