CurrentBlue Cross Blue Shield - LouisianaPolicy 00961

Surgical Treatment of Tarlov Cyst

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This policy governs coverage for surgical and percutaneous treatments of Tarlov (perineural) cysts for members of Blue Cross and Blue Shield of Louisiana across all products, specifying investigational stance and applicable treatment considerations.

Policy Summary

PayerBlue Cross Blue Shield - Louisiana

PolicySurgical Treatment of Tarlov Cyst

Policy CodePolicy 00961

Change TypeNo material change

Effective DateAug 1, 202613d

Next Review DateMay 1, 2027

Key ActionObtain prior authorization and document detailed clinical history, imaging, prior conservative treatments, and rationale when surgery for a symptomatic Tarlov cyst is proposed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Related Billing Codes

CPT-64999-UNLISTED-NERVOUS-SYSTEM-PROCEDURE

CPT 64999: Unlisted Nervous System Procedure

CPT-63268-SACRAL-SPINE-EXTRADURAL-GROWTH-LAMINECTOMY

CPT 63268: Sacral Spine Extradural Growth Removal via Laminectomy

CPT-63272-LUMBAR-INTRADURAL-TUMOR-REMOVAL-LAMINECTOMY

CPT 63272: Lumbar Intradural Tumor Removal via Laminectomy

CPT-63271-THORACIC-INTRADURAL-LESION-RESECTION-LAMINECTOMY

CPT 63271: Thoracic Intradural Lesion Resection via Laminectomy

CPT-63273-SACRAL-LAMINECTOMY-INTRADURAL-LESION-EXCISION

CPT 63273: Sacral Laminectomy with Intradural Lesion Excision

CPT-63266-THORACIC-EXTRADURAL-MASS-EXCISION-LAMINECTOMY

CPT 63266: Thoracic Extradural Mass Excision via Laminectomy

CPT-63265-CERVICAL-EXTRADURAL-GROWTH-REMOVAL-LAMINECTOMY

CPT 63265: Cervical Extradural Growth Removal via Laminectomy

CPT-63267-LUMBAR-EXTRADURAL-LESION-LAMINECTOMY

CPT 63267: Lumbar Extradural Lesion Evacuation via Laminectomy

CPT-63270-CERVICAL-INTRADURAL-TUMOR-RESECTION-LAMINECTOMY

CPT 63270: Cervical Intradural Tumor Resection via Laminectomy

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Coverage Determinations

Coverage criteria — surgical treatment

Covered when ALL of the following are met:

ALL of the following

The request is for surgical treatment of a Tarlov cyst (also known as perineural cyst, sacral perineural cyst, or sacral meningeal cyst).
There is documentation of symptoms reasonably attributable to the Tarlov cyst, such as chronic sacral/coccygeal pain, radiculopathy, leg weakness, bowel or bladder dysfunction, or sexual dysfunction; and conservative management (e.g., medication, physical therapy, or noninvasive measures) has been attempted without adequate symptom improvement when clinically appropriate;
Document dates and therapies attempted
Imaging correlates symptoms and demonstrates a cystic lesion consistent with a Tarlov cyst at the anatomic site corresponding to the clinical findings (e.g., MRI findings).
The treating surgeon provides a rationale that surgery is expected to relieve nerve compression and/or other pathophysiologic mechanisms causing the patient’s symptoms, and describes the intended surgical technique (e.g., laminectomy/laminoplasty with cyst fenestration/obliteration, cyst wall repair, grafting or tissue transposition, sacroplasty, or other open microsurgical procedures).
Include operative plan and risk discussion
The patient is an appropriate surgical candidate based on overall health status and comorbidities, and the anticipated benefits outweigh the risks of surgery, as documented in the medical record.

Billing Codes and Diagnosis Codes

Regulatory / coding notemixed

Treatment for Tarlov cysts is a surgical or percutaneous procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration (FDA). To date, the FDA has not approved any neuromodulation devices for the indication of Tarlov cysts.

Codes used to identify services associated with this policy (CPT)CPT

63265
63266
63267
63268
63270
63271
63272
63273
64999

ICD-10 DiagnosisICD-10

G96.191

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for surgical treatment of Tarlov cysts. Surgical procedures billed for treatment of Tarlov cysts should have prior authorization submitted to the plan before the procedure is performed.

Affected CPT codes may include: 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 64999.
Authorization requests should include operative plan and indication tied to imaging and clinical findings.

Denial Risk

Lack of High-Quality Comparative Evidence

The evidence base lacks high-quality comparative studies (no randomized controlled trials and limited comparative prospective data) directly comparing surgical techniques to percutaneous or conservative management. Because of this limited and low-quality evidence, surgical treatment is considered investigational and may be denied.

Clinical Background and Epidemiology

Tarlov (perineural) cysts are cerebrospinal fluid–filled sacs that arise near the dorsal root ganglion, most commonly in the sacral region. Many cysts are asymptomatic, but a minority produce symptoms such as sacral or coccygeal pain, radiculopathy, and bowel, bladder, or sexual dysfunction. Diagnosis is based on a focused clinical history and neurological examination with dedicated lumbar and sacral MRI (axial and sagittal planes); when needed to demonstrate communication with the subarachnoid space, CT myelography with delayed imaging or diagnostic aspiration can be used. The clinical course varies, and treatment is directed at the patient’s symptoms; evidence evaluating surgical versus percutaneous versus conservative management is limited and largely observational.

Key Definitions

Tarlov cyst (TC) definition

TermTarlov cyst (TC)

DefinitionA cerebrospinal fluid–filled sac located between the perineurium and endoneurium arising near the dorsal root ganglion; may contain spinal nerve root fibers and can affect spinal nerve roots, most commonly in the sacral region.

Alternate locationsAlthough most common in the sacrum, TCs can occur anywhere along the spine (lumbar, thoracic, cervical).

Wide-necked cyst definition

TermWide-necked cyst

DefinitionA Tarlov cyst with a large communication pore to the subarachnoid space characterized by high-flow CSF communication and rapid refilling.

Denial Risk

Coding and Investigational Mismatch May Be Denied

Coding that indicates an investigational service without prior authorization or documentation supporting medical necessity may result in claim denial. Ensure billed procedure and diagnosis codes appropriately reflect the service rendered and the clinical indication.

Common procedure codes associated with this policy: 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 64999.
ICD-10 diagnosis referenced in policy: G96.191.
Claims with coding/coverage mismatch (e.g., codes for surgical repair submitted when service is investigational and undocumented) may be denied.

Documentation Required

Required Clinical Documentation

Required clinical documentation must accompany authorization requests and claims to support the medical necessity of the proposed intervention.

Complete clinical history and neurologic examination.
High-quality imaging reports (dedicated lumbar and sacral MRI in axial and sagittal planes; CT myelography or delayed imaging if MRI is inconclusive).
Documentation of prior conservative and/or percutaneous treatments tried and duration of therapy.
Operative notes or planned operative report when applicable.
Objective testing results when relevant (e.g., urodynamic testing, anorectal manometry).

Documentation Required

Clinical Documentation Should Describe Symptoms Attributable to Tarlov Cysts

Clinical documentation should clearly describe symptoms attributable to the Tarlov cyst(s) and link those symptoms to the anatomic location of the cyst with dermatomal correlation and, where feasible, diagnostic procedures demonstrating the cyst as the pain generator.

Symptom description (pain distribution, radiculopathy, bowel/bladder/sexual dysfunction) with duration and severity.
Correlation of symptoms to cyst-bearing nerve roots (dermatomal charting).
Results of diagnostic blocks or cyst aspiration if performed to identify symptomatic cyst(s).
Imaging evidence that the cyst correlates anatomically with the reported symptoms and documents size, neck morphology (narrow vs wide), and any bone erosion.

Documentation Required

Claims Documentation

Claims documentation must include copies or summaries of the clinical records and imaging reports used to justify medical necessity and prior authorization decisions. Failure to submit adequate documentation may result in claim denial or delay.

Include prior authorization approval number on claim where applicable.
Attach or make available clinical notes, imaging reports, diagnostic test results, and prior treatment records supporting the indication.
If prior authorization was denied, include any appeal or additional documentation when resubmitting claims.

Note

Sequencing of Care — Consider Nonoperative Management and Percutaneous Techniques Before Surgery

Care should be sequenced from conservative to more invasive interventions. Nonoperative management and less invasive percutaneous techniques should be considered and documented as tried and failed prior to consideration of surgery.

Conservative measures: analgesics, NSAIDs, neuropathic agents, physical therapy, and other symptom-directed therapies.
Percutaneous image-guided interventions (e.g., cyst aspiration with fibrin sealant) when appropriate and when documented as attempted or considered.
Document duration and response to each therapy; note reasons surgery is being considered despite prior measures.

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OpenPayer

Surgical Treatment of Tarlov Cyst

Related Billing Codes

Coverage Determinations

Billing Codes and Diagnosis Codes

Provider Requirements, Prior Authorization, and Documentation

Clinical Background and Epidemiology

Key Definitions