CurrentCentenePolicy CP.MP.174

Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy

Defines medical necessity criteria, coding, and coverage stance for selective dorsal rhizotomy (SDR) in children with spastic cerebral palsy for Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicySelective Dorsal Rhizotomy for Spasticity in Cerebral Palsy

Policy CodePolicy CP.MP.174

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization with clinical documentation showing all medical necessity criteria are met before performing SDR.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

GMFCS II-IIIPreferred functional levels for SDR

Age >2 to <10 yrsAge range specified for eligibility

Reimers <40%Radiographic hip subluxation threshold

No botox ≤6 moPre-procedure treatment timing

CPT 63185,63190Procedure codes referenced

Coverage and Medical Necessity Criteria

Medical necessity criteria for SDR

Covered when ALL of the following are met:

Eligibility criteria for SDR

Diagnosis: Spastic diplegia, or spastic quadriplegia with no significant ataxia or dystonia
Functional level: GMFCS level II or III
Age greater than 2 years and less than 10 years
Strength: No significant muscle weakness

Policy Summary

PayerCentene

PolicySelective Dorsal Rhizotomy for Spasticity in Cerebral Palsy

Policy CodePolicy CP.MP.174

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization with clinical documentation showing all medical necessity criteria are met before performing SDR.

SourceLink

On This Page

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Rehabilitation capacity: Functional and intellectual ability to participate in physical rehabilitation

Conservative therapy: Failure of or inability to tolerate other conservative treatment (e.g., pharmacotherapy, orthopedic management, physical therapy)

Botulinum timing: No botulinum toxin A injection has been given within the last six months

Orthopedic surgery timing: No orthopedic surgery within the last year

Spine: No significant scoliosis

MRI findings: Periventricular leukomalacia (PVL) on MRI with no involvement of the thalamus, basal ganglia or cerebellum

Hip subluxation: Reimers index < 40% (no significant femoral head subluxation on pelvic radiograph)

Not medically necessary

Excluded indications: Selective dorsal rhizotomy is not medically necessary for children with spastic hemiplegia, or ataxic or athetoid spasticity

From policy section II

Selective dorsal rhizotomy (SDR) is not indicated for patients with spastic hemiplegia. The policy states that SDR is considered not medically necessary for children with spastic hemiplegia and therefore requests for SDR in this population do not meet coverage criteria.

Selective dorsal rhizotomy is not medically necessary for children with spastic hemiplegia, or with ataxic or athetoid spasticity. Requests for SDR for members presenting these diagnoses will be denied because they do not meet the policy’s covered indications.

Coding and Related Criteria

Referenced CPT CodesCPT

63185	Laminectomy with rhizotomy; 1 or 2 segments
63190	Laminectomy with rhizotomy; more than 2 segments

inv-06: Reimers index — numeric threshold used in eligibility (< 40%)

Reimers index thresholdReimers index < 40% (no significant femoral head subluxation on pelvic radiograph)

Measurement contextUsed on pelvic radiograph to assess hip subluxation prior to SDR

Relevance to eligibilityRequired criterion (must be < 40%) for medical necessity of SDR

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for selective dorsal rhizotomy (SDR). The provider must obtain prior authorization and submit supporting clinical documentation demonstrating that the member meets the policy criteria for SDR.

Affected procedure: Selective Dorsal Rhizotomy (SDR) — CPT 63185, 63190
Submit prior authorization request with complete clinical records and planned operative CPT code

Denial Risk

Not Medically Necessary Conditions

Requests for SDR for patients with spastic hemiplegia, or with ataxic or athetoid spasticity are considered not medically necessary and should be denied.

Denial-risk: SDR is not covered for spastic hemiplegia, ataxic spasticity, or athetoid spasticity

Documentation Required

Required Clinical Documentation Elements

Clinical documentation submitted with the prior authorization must demonstrate the clinical elements required by policy. At minimum include diagnosis, GMFCS level, age, evidence of periventricular leukomalacia (PVL) on MRI without involvement of thalamus/basal ganglia/cerebellum, assessment of pelvic/hip status (e.g., Reimers index), and documentation of functional and cognitive ability to participate in rehabilitation.

Diagnosis specifying type of cerebral palsy (e.g., spastic diplegia or spastic quadriplegia)
GMFCS level documented (policy favors II or III)
Age documented (>2 and <10 years)
MRI report demonstrating PVL without deep nuclei or cerebellar involvement
Pelvic radiograph reporting Reimers index (<40%) or statement of no significant femoral head subluxation
Notes on functional and intellectual ability for postoperative rehabilitation

Documentation Required

Conservative Treatment Failure / Intolerance

Documentation must show failure of or intolerance to conservative treatments prior to SDR. Examples include trials of pharmacotherapy, botulinum toxin A (no injection within the last 6 months per policy), orthopedic management, and physical therapy. Also document absence of recent orthopedic surgery (no surgery within the last year) and absence of significant muscle weakness or scoliosis.

Evidence of trials and outcomes for pharmacologic therapy, botulinum toxin, and physical/orthopedic interventions
If botulinum toxin A was used, include dates (must be >6 months before SDR)
If prior orthopedic surgery, include date (must be >1 year before SDR)
Assessment ruling out significant muscle weakness and significant scoliosis

Definitions and Classification Tools

inv-12: Selective dorsal rhizotomy (SDR) — procedural definition and scope

DefinitionNeurosurgical selective division of lumbosacral afferent (sensory) rootlets at the conus or intervertebral foramina under intraoperative neurophysiological guidance to reduce lower‑extremity spasticity

Scope of procedurePerformed to reduce spasticity and improve mobility in children with cerebral palsy; may be done via single‑level laminotomy or less invasive techniques

Typical candidatesChildren with spastic diplegia or qualifying spastic quadriplegia who meet other medical necessity criteria (e.g., GMFCS II–III, age >2 to <10 years)

Operative detailSelective sectioning of sensory rootlets of the lumbosacral plexus guided by intraoperative neurophysiologic monitoring

inv-13: GMFCS — Gross Motor Function Classification System description and relevance

What GMFCS isGross Motor Function Classification System — a standardized tool to categorize functional motor impairment in children with cerebral palsy; levels I–V describe increasing impairment

Preferred functional levels for SDRGMFCS level II or III (specified medical necessity criterion)

Level II descriptionWalks in most settings; may have difficulty long distances and on uneven terrain; may use railing for stairs; limited running and jumping

Level III descriptionWalks with hand‑held mobility device; may use wheeled mobility for longer distances; may require assistance for transfers and stair negotiation

Background

Selective dorsal rhizotomy (SDR) is a neurosurgical procedure that achieves reduction of lower-extremity spasticity by selectively sectioning lumbosacral sensory (dorsal) rootlets under intraoperative neurophysiologic guidance. The intended clinical effect is durable reduction of spasticity in appropriately selected children with cerebral palsy, which may provide modest improvements in motor function when combined with postoperative physical rehabilitation.