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Spinal fusion – lumbar

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 will be used to determine your coverage.

Administrative process

Prior authorization is required for lumbar spine fusion surgery for degenerative spine conditions.

Prior authorization is not required for fusion surgery of the cervical and thoracic areas of the spine.

Lumbar spinal fusion surgery is covered per the indications listed below.

The member is to be offered patient decision support.

This policy addresses the adult population. Spinal fusion surgery for children will be addressed on a case by case basis.

Indications that are covered without prior authorization

Lumbar fusions are considered medically necessary for spinal instability associated with any of the following conditions:

  • Epidural compression or vertebral destruction from tumor
  • Idiopathic scoliosis over 40 degrees
  • Instability after debridement for infection
  • Neural compression after spinal fracture
  • Pseudarthrosis
  • Spinal infections (including tuberculosis, osteomyelitis, discitis)
  • Acute cauda equina OR acute spinal cord compression syndrome
  • Acute spinal fracture from documented trauma.
  • Intra-operative spinal instability

Indications that require prior authorization

Lumbar fusions for patients with one or more of the following:

  • Chronic low back pain
  • Neurogenic claudication
  • Radicular pain
  • Progressive objective neurological deficit

Coverage Criteria

  1. Non-emergent spinal fusions must meet criteria A & B listed below AND the criteria listed for 2, 3 or 4 below:
    1. Member must have an evaluation at a Designated Medical Spine Center (MSC) prior to an orthopedic spine surgeon and neurosurgeon office consultation visit for specified lumbar spine surgery conditions;
    2. The visit summary notes from the MSC must be submitted with the request;
  2. For spinal fusion surgery for degenerative conditions with spinal instability or spinal stenosis associated with:
    1. One or more of the following diagnoses:
      1. Spondylolisthesis;
      2. Spinal stenosis;
      3. Spinal stenosis decompression likely to result in iatrogenic instability (greater than 50% facet joint excision bilaterally or entire facet on one side)
      4. Scoliosis (degenerative);
      5. Post laminectomy syndrome; or
      6. Progressive objective neurological deficit.
        -AND-
    2. Documentation by the operating surgeon demonstrating compliance with all of the following criteria:
      1. Documented unremitting pain and disability for at least 3 months that is refractory to intensive conservative therapy for at least 8 weeks. The course of intensive therapy must include all of the following:
        1. An active, organized, and progressive strength and flexibility program;
          Conservative therapy must include physical therapy (PT) and may include activity modification, weight loss, and drug therapy. Documentation must correspond to the current episode of pain (within 6 months).
          Formal physical therapy, including active muscle conditioning is REQUIRED, OR there must be an explicit statement in the clinical documents that explains why such physical therapy is contraindicated. Documentation of formal physical therapy would be the therapist’s notes.
        2. A psycho-educational component that deals with member expectations and perceptions as well as the anatomic sources of back pain;
        3. Documentation of less than 30% improvement in the Oswestry Disability Index (ODI) or Focus On Therapeutic Outcomes (FOTO) scores between starting conservative treatment and the day a decision to have surgery is made;
        4. A preoperative ODI that is still between 40% - 79% or FOTO Status Score that is still between 21 - 60.
      2. Radiographic documentation (plain radiographs, MRI/CT scans) of spinal instability.
      3. Absence of untreated, underlying, contributory mental health conditions or psychological issues (including but not limited to depression, drug or alcohol abuse).
      4. If the ODI score is greater than 80% or the FOTO score is less than 20, preoperative psychiatric/psychological evaluation conducted by a licensed psychiatrist, psychologist or other licensed mental health professional who has a working knowledge of the psychological issues involved in chronic pain syndromes.
      5. Documentation must include ODI or FOTO scores from the first and last therapy visits prior to surgery that demonstrate less than 30% improvement and a copy of the most recent pre-surgical ODI or FOTO member status.
      6. Documented degenerative disc disease limited to 1 to 2 disc levels, documented by appropriate diagnostic imaging as correlated with physical findings.
  3. For spinal fusion surgery for chronic discogenic back pain alone (without instability of deformity) (Chronic is defined as discogenic back pain having lasted equal to or longer than one year)
    1. Documentation by the operating surgeon demonstrating compliance with all of the following criteria:
      1. Documented unremitting, discogenic pain and disability for at least 1 year that is refractory to intensive conservative therapy for at least 8 weeks. The course of intensive conservative therapy must include all of the following:
        1. An active, organized, and progressive strength and flexibility program;
          Conservative therapy must include physical therapy (PT) and may include activity modification, weight loss, and drug therapy. Documentation must correspond to the current episode of pain (within 6 months).
          Formal physical therapy, including active muscle conditioning is REQUIRED, OR there must be an explicit statement in the clinical documents that explains why such physical therapy is contraindicated. Documentation of formal physical therapy would be the therapist’s notes.
        2. A psycho-educational component that deals with patient expectations and perceptions as well as the anatomic sources of back pain;
        3. Documentation of less than 30% improvement in the Oswestry Disability Index (ODI) or FOTO scores between starting conservative treatment and the day a decision to have surgery is made;
        4. A preoperative ODI that is still between 40% - 79% or FOTO Status Score that is still between 21 - 60.
      2. Preoperative psychiatric/psychological evaluation conducted by a licensed psychiatrist, psychologist or other licensed mental health professional who has a working knowledge of the psychological issues involved in chronic pain syndromes.
      3. Documentation must include ODI or FOTO scores from the first and last therapy visits prior to surgery that demonstrate less than 30% improvement and a copy of the most recent pre-surgical ODI or FOTO patient status.
      4. Documented degenerative disc disease limited to 1 to 2 disc levels, documented by appropriate diagnostic imaging as correlated with physical findings.
  4. For repeat spinal fusion surgery, including post laminectomy syndrome
    1. Documentation by the operating surgeon demonstrating compliance with all of the following criteria:
      1. Documented unremitting pain and disability for at least 6 months that is refractory to intensive conservative therapy for at least 8 weeks. The course of intensive conservative therapy must include all of the following:
        1. An active, organized, and progressive strength and flexibility program;
          Conservative therapy must include physical therapy (PT) and may include activity modification, weight loss, and drug therapy. Documentation must correspond to the current episode of pain (within 6 months).
          Formal physical therapy, including active muscle conditioning is REQUIRED, OR there must be an explicit statement in the clinical documents that explains why such physical therapy is contraindicated. Documentation of formal physical therapy would be the therapist’s notes.
        2. A psycho-educational component that deals with member expectations and perceptions as well as the anatomic sources of back pain;
        3. Documentation of less that 30% improvement in the Oswestry Disability Index (ODI) scores between starting conservative treatment and the day a decision to have surgery is made;
        4. A preoperative ODI that is still between 40% - 79% or FOTO Status Score that is still between 21 - 60.
      2. Preoperative psychiatric/psychological evaluation conducted by a licensed psychiatrist, psychologist or other licensed mental health professional who has a working knowledge of the psychological issues involved in chronic pain syndromes;
      3. Documentation must include Oswestry Disability Index (ODI) or FOTO scores from the first and last therapy visits prior to surgery that demonstrate less than 30% improvement and a copy of the most recent pre-surgical ODI or FOTO member status.
      4. Documented degenerative disc disease limited to 1 to 2 disc levels, documented by appropriate diagnostic imaging as correlated with physical findings.

Indications that are not covered

Lumbar fusions are not considered medically necessary or covered for the management of the following conditions:

  • With initial primary laminectomy/discectomy for nerve root decompression without documented instability;
  • Multiple-level degenerative disc disease (more than 2 disc levels);
  • Minimally invasive facet fusions;
  • Absence of an evaluation at a Designated Medical Spine Center; and
  • All other conditions not listed under “Indications that are covered”

Lumbar fusions with any of the following devices or techniques are not covered because the following are considered experimental or investigational:

  • Anterior interbody fusion or implantation of intervertebral body fusion devices using a laparoscopic approach;
  • Axial interbody approach (AxiaLif®);
  • Dynamic spine stabilization device systems (e.g., Dynesys®, Stabilimax NZ®);
  • Interspinous Process Decompression to treat spinal stenosis (e.g., X-STOP®);
  • Stand alone Spire™ plate for fusion

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).

Designated Medical Spine Center – is a clinic 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 guidelines and evidence driven protocols.

Designated Medical Spine Specialist – is a clinican with a specialty in Physical Medicine. 

Focus On Therapeutic Outcomes (FOTO) - a physical functional status score. This measure is used to assess functional status of patients who received outpatient rehabilitation through the use of self-report health status questionnaires. Measures are taken at intake, during, and at discharge from rehabilitation to assess changes in functional status. Measure results are available in Outcomes Profile Reports, which provide 1) information for clinicians to help direct and improve the care of their patients in real time during treatment, and once treatments are complete, 2) a comparison of the clinician's or facility's outcomes and the National Aggregate in the FOTO® Database.

Kyphosis - A posterior curvature of the thoracic spine usually the result of a disease (lung disease, Paget's disease) or a congenital problem.

Oswestry Disability Index (ODI) - a commonly used outcome-measure questionnaire for low back pain. It is a self-administered questionnaire divided into ten sections designed to assess limitations of various activities of daily living. Each section is scored on a 0–5 scale, 5 representing the greatest disability. The index is calculated by dividing the summed score by the total possible score, which is then multiplied by 100 and expressed as a percentage.

Spinal Stenosis - An abnormal narrowing of the spinal canal that may be either congenital or acquired. Treatment is generally surgical to widen the spinal canal. Laminectomy may be the indicated surgical procedure to reduce pressure on the spinal cord.

Spondylolisthesis - Forward movement of one building block of the spine (vertebra) in relation to an adjacent vertebra.

Scoliosis - a congenital lateral curvature of the spine.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The following CPT codes require prior authorization EXCEPT for the ICD 9 diagnosis codes listed below:

22533 - Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare
interspace (other than for decompression); lumbar
22534 - Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare
interspace (other than for decompression); thoracic or lumbar, each additional vertebral
segment (List separately in addition to code for primary procedure)
22558 - Arthrodesis, anterior interbody technique, including minimal discectomy to prepare
interspace (other than for decompression); lumbar
22585 - Arthrodesis, anterior interbody technique, including minimal discectomy to prepare
interspace (other than for decompression); each additional interspace (List separately
in addition to code for primary procedure)
22612 - Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without
lateral transverse technique)
22614 - Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral
segment (List separately in addition to code for primary procedure)
22630 - Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to
prepare interspace (other than for decompression), single interspace; lumbar
22632 - Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to
prepare interspace (other than for decompression), single interspace; each additional
interspace (List separately in addition to code for primary procedure)
22633 - Arthrodesis, combined posterior or posterolateral technique with posterior interbody
technique including laminectomy and/or discectomy sufficient to prepare interspace
(other than for decompression), single interspace and segment; lumbar
22634 - Arthrodesis, combined posterior or posterolateral technique with posterior interbody
technique including laminectomy and/or discectomy sufficient to prepare interspace
(other than for decompression), single interspace and segment; each additional interspace
and segment (List separately in addition to code for primary procedure)
22800 - Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments
22802 - Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments
22804 - Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral
segments
22808 - Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments
22810 - Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments
22812 - Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments
22840 - Posterior non-segmental instrumentation (e.g., Harrington rod technique, pedicle fixation
across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1,
facet screw fixation)
22841 - Internal spinal fixation by wiring of spinous processes (List separately in addition to code for
primary - procedure)
22842 - Posterior segmental instrumentation (e.g., pedicle screw fixation, dual rods with multiple
hooks and sublaminar wires); 3 to 6 vertebral segments
22843 - Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and
sublaminar wires); 7 to 12 vertebral segments
22844 - Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and
sublaminar wires); 13 or more vertebral segments
22851 - Application of intervertebral biomechanical device(s) (e.g., synthetic cage(s), threaded bone
dowel(s), methylmethacrylate) to vertebral defect or interspace
22899 - Unlisted procedure, spine
0195T - Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without
instrumentation, with image guidance, includes bone graft when performed; L5-S1
interspace
0196T - Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without
instrumentation, with image guidance, includes bone graft when performed; L4-L5
interspace (List separately in addition to code for primary procedure) 
0309T - Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy,
with posterior instrumentation, with image guidance, includes bone graft, when performed,
lumbar, L4-L5 interspace (List separately in addition to code for primary procedure)

The following ICD-9 Codes do NOT require prior authorization:

013.50-013.56

Tuberculous abscess of spinal cord

015.00-015.06

Tuberculosis of vertebral column

137.3

Late effects of tuberculosis of bones and joints

170.2

Malignant neoplasm of vertebral column, excluding sacrum and coccyx

192.3

Malignant neoplasm of spinal meninges

198.3

Secondary malignant neoplasm of brain and spinal cord

198.4

Secondary malignant neoplasm of other parts of nervous system

198.5

Secondary malignant neoplasm of bone and bone marrow

225.3

Benign neoplasm of spinal cord

225.4

Benign neoplasm of spinal meninges

237.5

Neoplasm of uncertain behavior of brain and spinal cord

237.6

Neoplasm of uncertain behavior of meninges

238.0

Neoplasm of uncertain behavior of bone and articular cartilage

344.60

Cauda equina syndrome without mention of neurogenic bladder

344.61

Cauda equina syndrome with neurogenic bladder

344.9

Unspecified paralysis

714.0

Rheumatoid Arthritis

718.88

Other joint derangement, not elsewhere classified, other specified site

722.70

Intervertebral disc disorder with myelopathy, unspecified region

722.73

Intervertebral lumbar disc disorder with myelopathy, lumbar region

724.6

Disorders of sacrum

733.13

Pathologic fracture of vertebrae

733.81

Malunion of fracture

733.82

Nonunion of fracture

737.10

Kyphosis (acquired) (postural)

737.30-737.34

Kyphoscoliosis and scoliosis

805.00-805.9Fracture of vertebral column without mention of spinal cord injury

806.4

Closed fracture of lumbar spine with spinal cord injury

806.5

Open fracture of lumbar spine with spinal cord injury

839.30

Open dislocation, lumbar vertebra

The following ICD-9 Diagnoses DO require prior authorization.  This list is not all inclusive.

 

721.90

Spondylosis of unspecified site without mention of myelopathy

722.10

Displacement of lumbar intervertebral disc without myelopathy

722.52

Degeneration of lumbar or lumbosacral intervertebral disc

722.83

Postlaminectomy syndrome, lumbar region

724.02

Spinal stenosis of lumbar region

724.2

Lumbago

737.39

Other kyphoscoliosis and scoliosis

737.40

Curvature of spine associated with other conditions

737.41

Kyphosis associated with other condition

737.42

Lordosis associated with other condition

737.43

Scoliosis associated with other condition

738.4

Acquired spondylolisthesis

756.11

Congenital spondylolysis, lumbosacral region

756.12

Congenital spondylolisthesis

756.19

Anomalies of spine. Other

839.20

Closed dislocation, lumbar vertebra

Diagnosis Codes that are not associated with the scope of this policy & do not require prior authorization, include but is not limited to:

721.0

Cervical spondylosis without myelopathy

721.1

Cervical spondylosis with myelopathy

721.2

Thoracic spondylosis without myelopathy

721.41

Spondylosis with myelopathy, thoracic region

722.0

Displacement of cervical intervertebral disc without myelopathy

722.11

Displacement of thoracic intervertebral disc without myelopathy

722.4

Degeneration of cervical intervertebral disc

722.51

Degeneration of thoracic or thoracolumbar intervertebral disc

722.71

Intervertebral cervical disc disorder with myelopathy, cervical region

722.72

Intervertebral thoracic disc disorder with myelopathy, thoracic region

839.21

Closed dislocation, thoracic vertebra

839.31

Open dislocation, thoracic vertebra

952.00 – 09

Spinal cord injury without evidence of spinal bone injury - cervical

952.10 – 19

Spinal cord injury without evidence of spinal bone injury - thoracic

Please see the Related content section at the right to see a list of ICD-10-CM codes associated with this policy.

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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.