Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy
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Defines medical necessity and exclusions for selective dorsal rhizotomy in children with spastic cerebral palsy and lower extremity spasticity for health plans affiliated with Centene (applied by Arizona Complete Health).
No material clinical or coverage changes in this revision.
Coverage Criteria for Selective Dorsal Rhizotomy
Medical necessity criteria
Covered when ALL of the following are met:
All listed criteria must be satisfied for medical necessity.
Not medically necessary
Not covered / Not medically necessary when ANY of the following apply:
Policy explicitly states SDR is not medically necessary for these presentations.
Selective dorsal rhizotomy (SDR) is not medically necessary for children with spastic hemiplegia or for those with ataxic or athetoid spasticity. Requests for SDR for these presentations do not meet the policy’s coverage criteria and may be denied.
The use of SDR in children with severe motor impairment (GMFCS level IV or V) is considered controversial and is not medically necessary under the policy’s standard criteria. In severely affected, non‑ambulatory patients the procedure is primarily palliative, may require more extensive root division, and carries a higher risk of resultant weakness; therefore standard SDR coverage is not supported except in rare, select cases where palliative benefit is clearly documented.
Coding and Clinical Thresholds
Provider Requirements and Documentation
Prior authorization required — show all medical necessity criteria met
Prior authorization is required and the request must document that all listed medical necessity criteria are met: spastic diplegia (or selected spastic quadriplegia without significant ataxia/dystonia), GMFCS level II or III, age > 2 and < 10 years, good trunk control and antigravity lower extremity strength, ability to participate in rehabilitation, failure/intolerance of conservative treatments, no botulinum toxin A within 6 months, no orthopedic surgery within 1 year, no significant scoliosis, PVL on MRI without thalamus/basal ganglia/cerebellum involvement, and Reimers index < 40%.
- Prior authorization must show all criteria in the policy are satisfied before SDR is authorized.
Conservative therapy prerequisite — document failed or not tolerated
Documented trial of and failure of (or intolerance to) conservative therapies is required prior to consideration of SDR. Conservative measures include pharmacotherapy, nerve blocks (botulinum toxin A and/or phenol), orthopedic management, physical therapy/occupational therapy, braces/orthotics and mobility devices.
- Policy requires failure of or inability to tolerate other conservative treatment (explicit examples listed).
- No botulinum toxin A injection within the last six months is required before SDR.
Required clinical and coding documentation to support medical necessity
Provide clinical and coding documentation that supports medical necessity: diagnosis/subtype (spastic diplegia or appropriate spastic quadriplegia), GMFCS level (II or III), patient age, clinical exam findings of trunk control and lower extremity antigravity strength, ability to participate in rehabilitation, prior conservative treatments and dates, MRI showing PVL without deep structure involvement, Reimers index < 40% on pelvic radiograph, and timing since last botulinum toxin or orthopedic surgery. Use CPT 63185 or 63190 as appropriate for rhizotomy reporting per coding guidance.
- Include dates for last botulinum toxin A injection and any orthopedic surgery to confirm required waiting intervals.
- Report Reimers index value (< 40%) from pelvic radiograph and MRI findings regarding PVL and deep structure involvement.
- Select CPT 63185 (1–2 segments) or 63190 (more than 2 segments) per procedure performed.
Exclusionary presentations — deny for specified presentations
Requests for SDR in children with spastic hemiplegia, or with ataxic or athetoid spasticity should be denied because the policy states SDR is not medically necessary for these presentations.
- Policy explicitly lists spastic hemiplegia and ataxic or athetoid spasticity as exclusionary presentations.
Background on Selective Dorsal Rhizotomy
Selective dorsal rhizotomy (SDR) is a neurosurgical procedure that selectively divides lumbosacral sensory rootlets to reduce lower‑extremity spasticity in children with cerebral palsy. It is most commonly indicated for patients with spastic diplegia (or selected spastic quadriplegia without significant ataxia or dystonia) who are young enough to relearn motor patterns and can participate in postoperative rehabilitation. While SDR can provide durable reductions in spasticity and potential functional benefits, it carries risks—including postoperative weakness and possible spinal deformity—and requires careful candidate selection and adherence to the policy criteria.
Definitions and Classification
Policy Revision History
Annual review; under I.D. replaced 'No significant muscle weakness' with 'Good trunk control…'; background updated; references reviewed and updated; reviewed by external and internal specialist.
Annual review; references reviewed and updated; background updated; reviewed by external and internal specialist.
Annual review with updated GMFCS level descriptions in the background; references reviewed and updated; reviewed by external specialist.
Annual review completed; minor background edits and references reviewed, reformatted and updated.
Annual review completed; minor edits to background and references reviewed, updated and reformatted; reviewed by specialist.
References reviewed and updated; background updated with no impact on criteria.
Policy developed and specialist reviewed; approval recorded.
Policy developed and specialist reviewed (initial revision log entries).
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