RE: Blue Cross Blue Shield of Michigan Transpsoas Approaches Medical Policy
Dear Dr Simmer:
On behalf of the members of the Council of Surgical Spine Societies (COSSS), we wish to thank
you for providing us with the opportunity to review the Blue Cross Blue Shield of Michigan
medical policy statement dated May 1, 2013. COSSS is dedicated to the best possible care for
patients with spinal disorders through investigation, education and advocacy.
In this policy statement, it is the position of Blue Cross Blue Shield of Michigan that transpsoas
approaches to the lumbar spine are considered experimental, investigational, and not medically
necessary. The basis of this statement is what is perceived to be the limited evidence in the
literature about the efficacy of this approach and concerns about its safety. The authors of the
current policy statement believe that further comparative studies are needed. Our response
addresses these assumptions and we urge you to amend your policy pursuant to our
recommendations outlined below.
Regarding the safety of this procedure, while early reports of neurological deficits related to
plexus injury may have been a concern, several recent studies have revealed much lower rates of
plexus injuries. As with any procedure, complications will often be recognized in the early
experience. It is this recognition that allows for surgeons to modify and evolve the
procedure. We invite the medical policy writers to review the more recent literature on this
topic. Rodgers et al., in 2010, reported a series of 600 patients undergoing lateral transpsoas
approaches. There was a rate of 0.7% transient postoperative neurological deficits. In this same
series, there were no wound infections, no vascular injuries, and no intraoperative visceral
injuries. This more recent data suggests a comparable complication profile to standard open
anterior fusions. As such, we do not believe that the lateral transpsoas procedure is unsafe, and
hence, experimental by default. Numerous recent studies have reported more concrete
understanding of the lumbosacral plexus anatomy and its relationship to the particular levels of
the lumbosacral spine.2-4 It is through this better understanding of the anatomy that a reduced
rate of nerve injuries is being achieved. Furthermore, when nerve injuries were encountered, it
is important to note that the vast majority of reported injuries have been transient. The more
recent literature demonstrates that these neuropathies and neuropraxias are self-limited. 5, 6 As
a result of the recent published studies on the transpsoas approach, we believe that CPT code
22558 accurately describes the work performed, and thus, this code should be correctly utilized
for surgeries where a discectomy and fusion from the lateral approach is performed.
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