Archived Policies - Surgery
Neuralgia Inducing Cavitational Osteonecrosis (NICO)
Diagnosis and treatment of neuralgia inducing cavitational osteonecrosis (NICO) are considered experimental, investigational, and unproven, including but not limited to:
Within the dental community, there are two schools of thought on the existence and importance of neuralgia inducing cavitational osteonecrosis (NICO). The proponents of NICO, who are primarily “biological dentists”, believe it is a newly identified form of avascular osteonecrosis (AO). AO most commonly affects the femur at the hip, but also can affect other bones such as the femur at the knee or the humerus at the shoulder, and is frequently the result of trauma or disease that damages blood supply to an area where there is not a lot of collateral circulation. However, many experts believe the jaw has abundant collateral circulation, and therefore believe AO does not occur there.
NICO lesions, or cavitations, can be either dead, hollow areas in the jaw bone, or holes filled with dead bone and bone marrow. These cavitations are believed to be the cause of facial pain, neuralgia, and headache, as well as pains and diseases located far from the mouth. Because these cavitations have no blood circulation, medications and other remedies cannot permeate the lesions, and the only recommended treatment is surgical removal of cavitational lesions by curettage of bony tissues. The excised material is biopsied to confirm the presence of inflammation or infection. NICO is believed to be a problem of chemical toxins and not bacterial infection, so antibiotics are thought to be of little value. Instead, some practitioners rinse the cavity with saline or colloidal silver and administer chelation therapy or intravenous vitamin C.
While dentists are able to diagnose abscesses, cysts, and other bone lesions with x-rays, NICO cavitations are reported to be difficult to discover and usually missed on most x-rays. Cavitat Medical Technologies, Inc. has developed the Cavitat Ultrasound Bone Densitometer (CAVITAT™) to aid medical professionals in diagnosing NICO. On their web site, Cavitat Medical Technologies, Inc. claims that the CAVITAT™ is the world’s leading technology in bone sonography imaging systems; reportedly CAVITAT™ imaging precisely identifies cavitational porosity in the jawbone. CAVITAT™ (Ultrasonograph) received U.S. Food and Drug Administration (FDA) 510K approval on February 15, 2002. In the 510K approval, the FDA classified the CAVITAT™ (Ultrasonograph) as an Extraoral X-Ray Unit. The FDA stated the technological characteristics of the CAVITAT™ (Ultrasonograph) are identical to those of a diagnostic pulse-echo ultrasound device, with the exception that the CAVITAT™ (Ultrasonograph) measures the signal that passes through the bone rather than the return or echo. Positive regions represent alveolar regions that attenuate ultrasound signals.
The clinical significance of NICO has not been established; many etiologies for NICO have been suggested, but none have been substantiated through research and scientific evidence. In addition, there is no agreement within the dental community on the clinical significance of these cavitations, and there are no clear diagnostic or treatment criteria that are widely accepted and integrated into clinical practice.
A MedLine search on the terms NICO, cavitational, and osteonecrosis located eight articles, six of which were authored or co-authored by one particular dentist who is a proponent of NICO; none of the articles report randomized, controlled studies on the diagnosis and/or treatment of NICO. The biopsies that have reportedly confirmed a diagnosis of NICO are performed on tissue that has been tested after-the-fact following invasive surgery. Further, the available literature suggests that only one specific pathologist has confirmed the NICO diagnosis on biopsy. In addition, an FDA 510K approval of the CAVITAT™ only addresses the safety and not the effectiveness of the device. In the 510K approval the FDA states, “The clinical significance and correlation of the CAVITAT™ (Ultrasonograph) images, including column height and color grading, has not been established for specific osseous pathology, or normal bone. Positive images represent alveolar regions that attenuate ultrasound signals.”
The diagnosis and treatment of NICO is not supported by a coverage position of the Centers for Medicare and Medicaid Services (CMS) or other authoritative guidelines.
An updated MedLine literature review was conducted through May 2008.. Diagnosis and treatment of NICO is not supported by evidence in the peer-reviewed medical literature that demonstrates an improvement in net health outcome and/or permits conclusions on the effect on health outcomes.
Sciubba (2009) reported that neuralgia-inducing cavitational osteonecrosis remains controversial. Changing etiologic concepts have led to confusion as well as the significant departures from the concept first defined by Ratner, which served as the basis for explaining the pain syndrome with features of trigeminal neuralgia. Since the earliest publications on the subject by Bouquot and colleagues there have been many challenges and counterclaims to the concept introduced, with a discussion of these included. Finally, absence of any form of research design and approval by institutional review panels remains a weakness in terms of acceptance of the information provided in the literature said to support the stated etiology of this entity.
The American Association of Endodontists (AAE) published a 2012 Position Statement on NICO lesions (Neuralgia-Inducing Cavitational Osteonecrosis) that states they "cannot condone surgical interventions intended to treat suspected NICO lesions. Even when a NICO lesion is suspected to be associated with an endodontically treated tooth, no surgical procedures should be performed until orofacial pain specialists confirm the diagnosis. It is also recommended that the treatment be performed and followed up by the orofacial pain specialists. In addition, the practice of recommending the extraction of endodontically treated teeth for the prevention of NICO, or any other disease, is unethical and should be reported immediately to the appropriate stated board of dentistry.”
A search of peer reviewed literature through June 2013 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.
Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
NOTE: On their web site, Cavitat Medical Technologies, Inc. states that the “American Medical Association has assigned a CPT coding number 76977 for CAVITAT™ scans and interpretations.” The AMA assigned 76977 in 1998 to be used for billing of bone mineral density tests in peripheral sites such as the wrist, fingers, or heel, primarily as a portable screening tool; the CAVITAT™ received FDA 510K approval in February 2002. Also, CPT code 76977 is for ultrasound bone density measurement and interpretation, peripheral site(s), any method. The 510K approval for CAVITAT™ specifies that the CAVITAT™ is substantially equivalent to the MYSONO™, which is a general ultrasound device that is used for general ultrasound imaging purposes.
NOTE: Some dentists believe NICO can cause illnesses that are remote from the mouth, including symptoms typical of arthritis, heart disease, and other bodily pain. Therefore, diagnosis codes given may vary widely.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.
The following codes may be applicable to this Medical policy and may not be all inclusive.
21025, 21026, 21030, 21040, 21046, 21047, 21048, 21049, 21210, 21215, 76977, 76999
ICD-9 Diagnosis Codes
526.4, 526.5, 733.45, 350.1-350.9, 352.1, 522.5, 522.6, 522.7, 526.4, 730.18, 733.45
ICD-9 Procedure Codes
ICD-10 Diagnosis Codes
M27.2, M27.3, M87.08, M87.180, G50.0, GT50.1, G50.8, G50.9, G52.1, K04.7, K04.5, K04.6, M27.2, M86.38, M86.48, M86.58, M86.68, M86.8X8, M87.08, M87.180
ICD-10 Procedure Codes
0NBR0ZZ, 0NBR4ZZ, 0NBR3ZZ, 0NBS0ZZ, 0NBS3ZZ, 0NBS4ZZ, 0NBT4ZZ, 0NBT3ZZ, 0NBT0ZZ, 0NQR, 0NQS, 0NRT, 0NTT0ZZ, 0NTV0ZZ,
The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.
The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.
A national coverage position for Medicare may have been developed or changed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov.
8/1/2013 Literature reviewed. No change.
7/1/2008 Revised/updated entire document. This policy is no longer scheduled for routine literature review and update.
2/1/2006 New medical document
|Title:||Effective Date:||End Date:|
|Neuralgia Inducing Cavitational Osteonecrosis (NICO)||01-15-2018||11-14-2018|
|Neuralgia Inducing Cavitational Osteonecrosis (NICO)||08-01-2016||01-14-2018|
|Neuralgia Inducing Cavitational Osteonecrosis (NICO)||10-15-2015||07-31-2016|
|Neuralgia Inducing Cavitational Osteonecrosis (NICO)||12-15-2014||10-14-2015|
|Neuralgia Inducing Cavitational Osteonecrosis (NICO)||08-01-2013||12-14-2014|
|Neuralgia Inducing Cavitational Osteonecrosis (NICO)||07-01-2008||07-31-2013|
|Neuralgia Inducing Cavitational Osteonecrosis (NICO)||05-03-2006||06-30-2008|
|Neuralgia Inducing Cavitational Osteonecrosis (NICO)||02-01-2006||05-02-2006|