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Clinical Policy Bulletin:
Brachial Plexus Surgery
Number: 0850


Policy

  1. Aetna considers neuroplasty (neurolysis or nerve decompression) medically necessary the treatment of a brachial plexus neuromas and other brachial plexus lesions.
  2. Aetna considers dorsal root entry zone (DREZ) coagulation medically necessary in the treatment of brachial plexus avulsion.
  3. Aetna considers computer-assisted dorsal root entry zone microcoagulation (CA-DREZ) experimental and investigational in the treatment of brachial plexus avulsion because there is inadequate evidence in the peer-reviewed published clinical literature regarding its effectiveness.
  4. Aetna considers triangle tilt surgery experimental and investigational in the treatment of obstetric brachial plexus injury because the clinical evidence is not sufficient to permit conclusions on the health outcome effects of triangle tilt surgery in the treatment of obstetric brachial plexus injury.
  5. Aetna considers the Mod-Quad procedure experimental and investigational in the treatment of obstetric brachial plexus injury because there is no clinical evidence to support the use of the Mod-Quad in the treatment of obstetric brachial plexus injury.


Background

The brachial plexus is a network of nerves located in the neck and axilla, composed of the anterior branches of the lower four cervical and first two thoracic spinal nerves that supply the chest, shoulder, and arm. Injuries to the brachial plexus affect the nerves supplying the shoulder, upper arm, forearm and hand, causing numbness, tingling, pain, weakness, limited movement, or even paralysis of the upper limb. Brachial plexus lesions are classified as either traumatic or obstetric. Brachial plexopathy is the pathologic dysfunction of the brachial plexus. When the brachial plexus is injured during delivery, the nerves become damaged and result in loss of muscle control and paralysis. This condition is also known as Erb’s palsy.

Brachial plexus avulsion is the tearing away or forcible separation of nerves of the brachial plexus (a network of nerves that conducts signals from the spine to the shoulder, arm and hand) from the spine, the point of origin. Symptoms of brachial plexus injuries may include a limp or paralyzed arm, lack of muscle control in the arm, hand, or wrist, and lack of feeling or sensation in the arm or hand. Brachial plexus injuries may occur during birth: the baby's shoulders may become impacted during the birth process causing the brachial plexus nerves to stretch or tear. 

Brachial neuroplasty (neurolysis or nerve decompression) is the surgical repair or restoration of nerve tissue. The release of adhesions around a nerve (freeing of intact nerve from scar tissue) is performed to relieve pain and disability. It is written in the 2008 textbook Frontera: Essentials of Physical Medicine and Rehabilitation, surgery is an option in cases of traumatic plexopathy but has variable results. Surgical techniques such as nerve grafting, free muscle transfer, neurolysis, and neurotization are used. Surgeons who use these techniques frequently differ considerably in their approach to them, making conclusions about their efficacy difficult. According  to the textbook Bradley: Neurology, the surgical treatment of traumatic plexopathy depends on the extent of the lesion. Depending on the findings, neurolysis, nerve grafting or re-neurotization is performed. In the textbook Browner; Skeletal Trauma it is written in reference to nerve injuries of the brachial plexus, when a neuroma in continuity is found it may be resected and repaired or neurolysis may be performed.

Dorsal root entry zone (DREZ) coagulation (also known as dorsal root entry zone lesion) is a surgical procedure in which ablative lesions are made at the dorsal root entry zones of the spinal cord. These lesions are made with a radiofrequency lesion generator or laser through an open exposure of the cord via laminectomy. Pain-producing nerve cells are destroyed with radiofrequency heat lesions.

Computer-assisted dorsal root entry zone microcoagulation (CA-DREZ) is a surgical procedure in which ablative lesions are made at the dorsal root entry zones of the spinal cord. These lesions are made with a radiofrequency lesion generator or laser through an open exposure of the cord via laminectomy. It involves electrical recording inside the spinal cord at the time of surgery to identify regions of abnormally active pain-producing nerve cells. These abnormal cells are then destroyed with radiofrequency heat lesions.

The Triangle Tilt is a surgical procedure that addresses scapular elevation in children with obstetric brachial plexus injury (OBPI) through the bony realignment of the clavicle and scapula. This realignment, or tilting, is of the triangle formed by clavicle and scapula. As the scapula elevates, the plane of the triangle is steepened. The purpose of the triangle tilt, therefore, is to normalize the plane of this triangle or, to reduce the elevation of the scapula and normalize the spatial relationship between the sides of the triangle.

Nath et al write in 2010 the triangle tilt surgery restores the distal acromioclavicular triangle from an abnormal superiorly angled position to a neutral position, thereby restoring normal glenohumeral anatomic relationships. The findings of a study investigating the effects of triangle tilt surgery on glenohumeral joint anatomy in 100 OBPI patients were reported. Axial computed tomography and magnetic resonance images taken before and 12- to 38-months after surgery showed significant improvements in both posterior subluxation and glenoid version. Patients with complete posterior glenohumeral dislocation improved from 19% preoperatively, to 11% postoperatively. Glenoid shape was also improved, with 81% of patients classified as concave or flat after surgery compared with 53% before surgery. The authors concluded these anatomic improvements after triangle tilt surgery hold promise for improving shoulder function and quality of life for OBPI patients.

The Mod Quad procedure is considered a secondary surgery in children with brachial plexus injury used to correct muscle imbalances. Among the muscles injured in Erb's are the abductors of the shoulder (that lift the arm over the head), as well as the external rotators (that help to turn the upper arm outward and to open the palm of the hand). At the same time, the internal rotators (muscles that turn the arm and palm inward) and adductors (muscles that pull the arm to the side) of the arm are not involved in the injury because they are supplied by the lower roots of the plexus. These strong muscles overpower the weak muscles and over time the child cannot lift the arm over the head or turn the palm out, because of the muscle imbalance. In order to use the hand effectively, the elbow becomes bent, which eventually becomes fixed because of weakness of the triceps (the elbow straightening muscle). The elbow-bent posture (also known as the Erb's Engram) contributes to the appearance of the arm being shorter. 

For this muscle imbalance, a group of muscle releases and transfers can put the arm in a more natural position and help to lift the arm over the head. Known as the "quad" procedure, it has four components:

  • latissimus dorsi muscle transfer for external rotation and abduction
  • teres major muscle transfer for scapular stabilization
  • subscapularis muscle release
  • axillary nerve decompression and neurolysis). Depending on the individual child, other nerve decompressions or muscle/ tendon transfers (such as pectoralis muscle releases) might be performed at the same time (the modified quad or "Mod Quad" procedure).
 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes not covered for indications listed in the CPB:
Triangle Tilt Surgery - no specific code:
Mod-Quad Procedure -  no specific code:
Neurolysis:
CPT codes covered if selection criteria are met:
64713
ICD-9 codes covered if selection criteria are met:
215.0 Other benign neoplasm of connective and other soft tissue; head, face and neck
215.2 Other benign neoplasm of connective and other soft tissue; upper limb, including shoulder
353.0 Brachial plexus lesions
767.6 Brachial plexus lesions
953.4 Injury to nerve roots and spinal plexus; brachial plexus
Dorsal root entry zone (DREZ) coagulation :
CPT codes covered if selection criteria are met: :
63170
64640
ICD-9 codes covered if selection criteria are met:
953.4 Injury to nerve roots and spinal plexus; brachial plexus [brachial plexus avulsion]
Computer-assisted dorsal root entry zone (CA-DREZ) coagulation:
CPT codes not covered for indications listed in the CPB :
+20985


The above policy is based on the following references:

Brachial Neuroplasty

  1. Bradley: Neurology in Clinical Practice. Fifth Edition. 2008.
  2. Browner: Skeletal Trauma. Fourth Edition. 2008.
  3. Canale & Beaty: Campbell's Operative Orthopaedics. Eleventh Edition. 2007.
  4. Frontera: Essentials of Physical Medicine and Rehabilitation. Second Edition. 2008.
  5. Kliegman: Nelson Textbook of Pediatrics. Eighteenth Edition. 2007.
  6. Krishnan KG et al. Traumatic lesions of the brachial plexus: an analysis of outcomes in primary brachial plexus reconstruction and secondary functional arm reanimation. Neurosurgery, 62(4): 873-85; discussion 885-6   2008.
  7. Shin AY et al. Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg, 13(6): 382-96 2005.

Computer-Assisted Dorsal Root Entry Zone (CA-DREZ) Microcoagulation:

  1. Daroff: Bradley's Neurology in Clinical Practice. Sixth Edition. 2012.
  2. Edgar RE et al. Computer-assisted DREZ microcoagulation: posttraumatic spinal deafferentation pain. J Spinal Disord, 6(1): 48-56 1993.
  3. Thomas DG; Jones SJ. Dorsal root entry zone lesions (Nashold’s procedure) in brachial plexus avulsion. Neurosurgery, 15(6): 966-8 1984.

Dorsal Root Entry Zone (DREZ) Coagulation:

  1. Friedman AH et al. Dorsal root entry zone lesions for the treatment of brachial plexus avulsion injuries: a follow-up study. Neurosurgery, 22(2): 369-73 1988.
  2. Prestor B. Microsurgical junctional DREZ coagulation for treatment of deafferentation pain syndromes. Surg Neurol, 56(4): 259-65 2001.
  3. Samii M et al. Treatment of refractory pain after brachial plexus avulsion with dorsal root entry zone lesions. Neurosurgery, 48(6): 1269-1277 2001.
  4. Schwartz: Principles of Surgery. Seventh Edition. 1999.
  5. Sindou MP et al. Microsurgical lesioning in the dorsal root entry zone for pain due to brachial plexus avulsion: a prospective series of 55 patients. J Neurosurg, 102(6): 1018-28  2005.
  6. Townsend:  Sabiston Textbook of Surgery. Seventeenth Edition. 2004.
  7. Thomas DG; Jones SJ. Dorsal root entry zone lesions (Nashold’s procedure) in brachial plexus avulsion. Neurosurgery, 15(6): 966-8 1984.

Triangle Tilt Surgery

  1. Nath RK et al. Surgical normalization of the shoulder joint in obstetric brachial plexus injury. Ann Plast Surg, 65(4): 411-7  2010.


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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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