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Coverage criteria policies

Spinal Lumbar Laminectomy

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for any laminectomy surgery (lumbar, cervical or thoracic).

Evaluation at a Designated Medical Spine Center (MSC) is required prior to the first office visit with a spine surgeon for specified lumbar conditions unless there is an emergent indication. The designated network requirement will be applied to patients residing in regions where patients have access to a medical spine specialist. Patients residing outside of those regions will be exempt from seeing a designated medical spine specialist. Please see the “Spine surgical practice – low back pain office visits” policy for details about these requirements.

Coverage

Spinal lumbar laminectomy surgery is covered. Evaluation at a Designated Medical Spine Center (MSC) is required prior to the first office visit with a spine surgeon for specified lumbar conditions unless there is an emergent indication. Please see the “Spine surgical practice – low back pain office visits” policy for details about these requirements.

Cervical & thoracic laminectomy are outside the scope of this policy. They are covered surgeries that do not require prior authorization, nor an evaluation at a MSC.

Indications that are covered

  1. Lumbar laminectomy surgeries are covered. Evaluation at a Designated Medical Spine Center (MSC) is required prior to the first office visit with a spine surgeon for specified lumbar conditions unless there is an emergent indication as described in criterion #2.
  2. An evaluation at an MSC is not required for observed, progressive neurologic deterioration from a lumbar spine condition that includes any of the following:
    1. Evidence of tumor, infection or acute fracture;
    2. Cauda equina syndrome;
    3. Sudden, progressive neurologic deterioration as evidenced by:
      1. Acute weakness or decreased muscle control of the leg(s); or
      2. Loss of bladder or bowel control; or
    4. Any other documented emergent neurological condition resulting from a lumbar spinal condition.

Definitions

Designated Medical Spine Centers: Designated Medical Spine Centers are clinics with medical spine specialists whose focus is on the non-surgical, comprehensive management of spine, neck and back problems using a biopsychosocial active re-conditioning model. A Designated Medical Spine Center has shown a commitment to evidence based practice as demonstrated by use of ICSI (Institute for Clinical Systems Improvement) guidelines and evidence driven protocols.

Designated Medical Spine Specialist: A medical spine specialist is a clinician with a specialty in Physical Medicine and Rehabilitation, Occupational Medicine, Sports Medicine or advanced extensive training in spine care.

Cauda equina: A bundle of spinal nerve roots, which arise from the termination of the spinal cord proper, it comprises the roots of all the spinal nerves below the first lumbar (L1).

Laminectomy is surgery to remove the lamina — the back part of the vertebra that covers your spinal canal. Also known as decompression surgery, laminectomy enlarges your spinal canal to relieve pressure on the spinal cord or nerves.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Chou R, Huffman L. Evaluation and management of low back pain: evidence review. Glenview, IL: American Pain Soc; 2007.
  2. Goertz M, Thorson D, Bonsell J, Bonte B, Campbell R, Haake B, Johnson K, Kramer C, Mueller B, Peterson S, Setterlund L, Timming R. Institute for Clinical Systems Improvement. Adult Acute and Subacute Low Back Pain. Updated November 2012.
  3. Levin K. Lumbar spinal stenosis: Treatment and prognosis. In: UpToDate, Aminoff M., Atlas S. (Ed), UpToDate, Waltham, MA. (Accessed on June 30, 2016.)
  4. Meena S., Sharma P., Chowdhury B. Management of thoracolumbar fractures. Indian J Neurosurg 2015;4:56–62.
  5. Rutkove S., Tarulli A. Polyradiculopathy: Spinal stenosis, infectious, carcinomatous, and inflammatory nerve root syndromes. In: UpToDate, Shefner J. (Ed), UpToDate, Waltham, MA. (Accessed on June 30, 2016.)
  6. Small SA, Perron AD, Brady WJ. Orthopedic pitfalls: Cauda equina syndrome. Am J Emerg Med. 2005;23(2):159-163
  7. Washington State Department of Labor and Industries. (2014). Medical treatment guidelines: Work-related acute cauda equina syndrome (CES).

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Policy activity

  • 12/15/2011 - Date of origin
  • 11/16/2017 - Effective date
Review date
  • 08/2016
Revision date
  • 07/18/2016

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