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Medical Policy

Subject: Cervical and Lumbar Spinal Procedures Medical Policy #: 25.1 Original Effective Date: 05/17/2010 Status: Reviewed Last Review Date: 05/26/2021

Disclaimer

Refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans or the plan may have broader or more limited benefits than those listed in this Medical Policy.

Coverage Determination

Prior Authorization is required, Log on to the NIA Magellan website: www.RadMD.com to submit a “Request an Exam”.

Presbyterian now uses NIA Magellan Lumbar Spinal .

NIA prior authorizes or manage the provider precertification for Musculoskeletal Surgery Services, and not the facility precertification. Musculoskeletal Surgery Services rendered through the Emergency Room are not managed by NIA. All other inpatient and outpatient Musculoskeletal surgery procedures are managed by NIA for the outlined below.

This Medical Policy includes information on the following items (Ctrl+Click to select):

Lumbar Spine Surgery Lumbar Spine Surgery Description Indication Exclusion Coding Lumbar (single level) Surgery Lumbar Spinal Fusion (multiple levels) Surgery Lumbar Decompression Procedures Lumbar /Microdiscectomy procedure

Cervical Spine Surgery Cervical Description Indications Coding Anterior Cervical Decompression with Fusion (ACDF) Single level Anterior Cervical Decompression with Fusion (ACDF) – Multiple level: Cervical Posterior Decompression with Fusion – Single Leve Cervical Posterior Decompression with Fusion- Multiple Levels: Cervical Artificial Disc – Single Level: Cervical Artificial Disc – Two Levels: Cervical Posterior Decompression (without fusion): Cervical Anterior Decompression (without fusion):

LUMBAR SPINAL SURGERY

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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Lumbar Lumbar Spinal Fusion Surgery Spine Surgery Lumbar Decompression Procedures Lumbar Microdiscectomy Only Procedures

Description This guideline outlines the key surgical treatments and indications for common lumbar spinal disorders and is a consensus document based upon the best available evidence. Spine surgery is a complex area of medicine and this document breaks out the treatment modalities for lumbar spine disorders into surgical categories: lumbar discectomy/microdiscectomy, lumbar decompression, and lumbar fusion surgery. Artificial disc replacement is an alternative to spinal fusion for the treatment of symptomatic disc disease. These devices are designed to maintain the function of the natural spine by preserving motion, and to potentially limit the incidence of adjacent segment degeneration. Presbyterian Health Plan covers cervical artificial disc replacement, but does not cover lumbar artificial disc replacement

Indication INDICATIONS FOR LUMBAR SURGERY: (This section of the clinical guidelines can be found on the NIA Magellan Clinical website, which thoroughly provides the clinical criteria for each of the lumbar and pre-sacral spine surgery categories.) I. Indications for Lumbar Discectomy/Microdiscectomy: Surgical indications for herniation: II. Indications for Lumbar Decompression: , , , and . These procedures allow decompression by partial or total removal of various parts of vertebral and . Surgical Indications for decompression due to lumbar : III. Indications for Lumbar Spine Fusion: IV. CONTRAINDICATIONS FOR SPINE SURGERY (Note:Cases will not be approved if the below contraindications exist): 1. Medical contraindications 2. Psychosocial risk factors. 3. Active Tobacco or Nicotine 4. Morbid Obesity

V. Other ADDITIONAL INFORMATION

Exclusion Services not covered: The following procedures are not covered as they are either still under investigation or are not recommended based upon the current evidence: • Percutaneous Lumbar Discectomy • Laser Discectomy • Percutaneous Radiofrequency Disc Decompression • Intradiscal Electrothermal Annuloplasty (IDEA or IDET) • Nucleus Pulpous Replacement • Pre-Sacral Fusion, or • Lumbar Artificial Disc Replacement

CODING The coding listed in this medical policy is for reference only. Covered and non-covered codes are within this list.

CPT Code Lumbar Spinal Fusion (single level) Surgery

Arthrodesis, lateral extracavitary technique, including minimal discectomy to 22533 prepare interspace; lumbar

Arthrodesis, anterior interbody technique, including minimal discectomy to 22558 prepare interspace; (other than for decompression); lumbar

Arthrodesis, posterior or posterolateral technique, single level; lumbar (with 22612 lateral transverse technique, when performed)

Arthrodesis, posterior interbody technique, including laminectomy and/or 22630 discectomy to prepare interspace, single interspace; lumbar

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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CPT Code Lumbar Spinal Fusion (single level) Surgery

Arthrodesis, combined posterior or posterolateral technique with posterior 22633 interbody technique including laminectomy and/or discectomy sufficient to prepare interspace, single interspace and segment; lumbar

For CPT codes listed above include also Decompression (see below for codes)

CPT Code Lumbar Spinal Fusion (multiple levels) Surgery

Arthrodesis, lateral extracavitary technique, including minimal discectomy to 22533 prepare interspace; lumbar

Arthrodesis, lateral extracavitary technique, including minimal discectomy to +22534 prepare interspace; thoracic or lumbar, each additional vertebral segment

Arthrodesis, anterior interbody technique, including minimal discectomy to 22558 prepare interspace; lumbar Arthrodesis, anterior interbody technique, including minimal discectomy to +22585 prepare interspace; each additional interspace. (List separately in addition to code for primary procedure) Code first (22554-22558)

22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar

Arthrodesis, posterior or posterolateral technique, single level; each additional +22614 vertebral segment. (List separately in addition to code for primary procedure) Code first (22612, 22630,22633) Arthrodesis, posterior interbody technique, including laminectomy and/or 22630 discectomy to prepare interspace, single interspace; lumbar Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace, single interspace; each additional +22632 interspace. (List separately in addition to code for primary procedure). Code first (22612, 22630, 22633) Arthrodesis, combined posterior or posterolateral technique with posterior 22633 interbody technique including laminectomy and/or discectomy sufficient to prepare interspace, single interspace and segment; lumbar Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to +22634 prepare interspace, single interspace and segment; each additional interspace and segment. (List separately in addition to code for primary procedure). Code first (22633)

For CPT codes listed above include also Decompression (see below for codes)

CPT Code Lumbar Decompression Procedures

Laminectomy with exploration and/or decompression of and/or 63005 cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; lumbar, except for . Laminectomy with removal of abnormal facets and/or pars inter-articularis with 63012 decompression of cauda equina and roots for spondylolisthesis, lumbar (Gill type procedure) Laminectomy with exploration and/or decompression of spinal cord and/or 63017 cauda equina, without facetectomy, foraminotomy or discectomy, more than 2 vertebral segments; lumbar Laminotomy, with decompression of nerve root(s), including partial 63030 facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar Laminotomy, with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; +63035 each additional interspace, cervical or lumbar. (List separately in addition to code for primary procedure). Code first (63020-63030)

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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CPT Code Lumbar Decompression Procedures

Laminotomy, (hemilaminectomy) with decompression of nerve root(s), 63042 including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar Laminotomy, (hemilaminectomy) with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated +63044 intervertebral disc, reexploration, single interspace; each additional lumbar interspace. (List separately in addition to code for primary procedure). First code (63042) Laminectomy, facetectomy and foraminotomy, (unilateral or bilateral with 63047 decompression of spinal cord, cauda equine and/or nerve root[s]. [e.g., spinal or lateral recess stenosis]), (single vertebral segment; lumbar Laminectomy, facetectomy and foraminotomy, (unilateral or bilateral with decompression of spinal cord, cauda equine and/or nerve root[s]. [e.g., spinal +63048 or lateral recess stenosis]), (single vertebral segment; each additional segment, cervical, thoracic, or lumbar. (List separately in addition to code for primary procedure). Code first (63045-63047). Transpedicular approach with decompression of spinal cord, equina and/or 63056 nerve root(s), single segment; lumbar. Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s), single segment; each additional segment, thoracic or lumbar. +63057 (List separately in addition to code for primary procedure). Code first (63055- 63056)

CPT Codes Lumbar Discectomy/Microdiscectomy procedure

Laminotomy, with decompression of nerve root(s), including partial 63030 facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar Laminotomy, with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; +63035 each additional interspace, cervical or lumbar. (List separately in addition to code for primary procedure). Code first (63020-63030) Endoscopic decompression of spinal cord, nerve root(s), including 62380 laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar.

Lumbar Artificial Disc Replacement CPT Codes (not payable, considered investigational) Total disc , anterior approach, including discectomy to prepare 22857 interspace, single interspace, lumbar

Revision including replacement of total disc arthroplasty, anterior approach, 22862 single interspace; lumbar

Removal of total disc arthroplasty, anterior approach, single interspace; 22865 lumbar

0163T, 0164T and 0165T Add-on codes for the above procedures are also non covered.

CERVICAL SPINAL SURGERY

Cervical Spine Surgery 1. Anterior Cervical Decompression with Fusion - Single Level (ACDF) 2. Anterior Cervical Decompression with Fusion - Multiple Level (ACDF) 3. Cervical Posterior Decompression with Fusion - Multiple Levels 4. Cervical Posterior Decompression with Fusion - Single Level 5. Cervical Artificial Disc - Single Level 6. Cervical Artificial Disc - Two Levels 7. Cervical Posterior Decompression (without fusion) Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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8. Cervical Anterior Decompression (without fusion)

Description This guideline outlines the key surgical treatments and indications for common cervical spinal disorders and is a consensus document based upon the best available evidence. Spine surgery is a complex area of medicine, and this document breaks out the clinical indications by surgical type. Operative treatment is indicated only when the natural history of an operatively treatable problem is better than the natural history of the problem without operative treatment. Choice of surgical approach is based on anatomy, the patient's pathology, and the surgeon's experience and preference. All operative interventions must be based on a positive correlation with clinical findings, the natural history of the disease, the clinical course, and diagnostic tests or imaging results. Artificial disc replacement is an alternative to spinal fusion for the treatment of symptomatic disc disease. These devices are designed to maintain the function of the natural spine by preserving motion, and to potentially limit the incidence of adjacent segment degeneration. Artificial disc replacements are available for the lumbar and cervical spine. Presbyterian Health Plan covers cervical artificial disc replacement, but does not cover lumbar artificial disc replacement

Indications INDICATIONS FOR CERVICAL SURGERY: This section of the clinical guidelines can be found on the Magellan Clinical guideline, which thoroughly provides the clinical criteria for the following: I. Anterior Cervical Decompression with Fusion (ACDF) - Single Level: II. Anterior Cervical Decompression with Fusion (ACDF) - Multiple Level: III. Cervical Posterior Decompression with Fusion - Single Level: IV. Cervical Posterior Decompression with Fusion - Multiple Levels: V. Cervical Posterior Decompression (w/o fusion): VI. Cervical Artificial Disc Replacement (Single or Two Level) VII. Cervical Anterior Decompression (without fusion) VIII.

CODING The coding listed in this medical policy is for reference only. Covered and non-covered codes are within this list.

CPT Codes Anterior Cervical Decompression with Fusion (ACDF) Single level Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2, with or without 22548 excision of odontoid process Arthrodesis, anterior interbody, including disc space preparation, discectomy, 22551 osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare 22554 interspace; cervical below C2 Additional Procedures Codes: • Vertebral : 63081, +63082, 63300, 63304, +63308 • Decompression: 63075, +63076 • Removal of Artificial Disc: 22864

CPT Codes Anterior Cervical Decompression with Fusion (ACDF) – Multiple level:

Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2, with or without 22548 excision of odontoid process

Arthrodesis, anterior interbody, including disc space preparation, discectomy, 22551 osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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CPT Codes Anterior Cervical Decompression with Fusion (ACDF) – Multiple level: Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical +22552 below C2, each additional interspace. (List separately in addition to code for primary procedure). Code first (22551)

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare 22554 interspace; cervical below C2

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare +22585 interspace; each additional interspace. (List separately in addition to code for primary procedure). Code first (22554). Additional Procedure Codes: • Vertebral Corpectomy: 63081, +63082, 63300, 63304, +63308 • Decompression: 63075, +63076 • Removal of Artificial Disc: 22864

CPT Codes Cervical Posterior Decompression with Fusion – Single Level

22590 Arthrodesis, posterior technique, craniocervical

22595 Arthrodesis, posterior technique, atlas-axis Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 22600 segment Additional Procedure Codes: • Decompression: 63001, 63015, 63020, +63035, 63040, +63043, 63045, +63048, 63050, 63051

CPT Codes Cervical Posterior Decompression with Fusion- Multiple Levels:

22590 Arthrodesis, posterior technique, craniocervical

22595 Arthrodesis, posterior technique, atlas-axis

Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 22600 segment Arthrodesis, posterior or posterolateral technique, single level; each additional +22614 vertebral segment. (List separately in addition to code for primary procedure). Code first (22600) Additional Procedure Codes: • Decompression: 63001, 63015, 63020, +63035, 63040, +63043, 63045, +63048, 63050, 63051

CPT Code Cervical Artificial Disc – Single Level:

Total disc arthroplasty, anterior approach, including discectomy with end plate 22856 preparation; single interspace, cervical

Revision including replacement of total disc arthroplasty, anterior approach, single 22861 interspace; cervical

22864 Removal of total disc arthroplasty, anterior approach, single interspace; cervical

CPT Code Cervical Artificial Disc – Two Levels:

Total disc arthroplasty, anterior approach, including discectomy with end plate 22856 preparation; single interspace, cervical

Total disc arthroplasty, anterior approach, including discectomy with end plate 22858 preparation; second level, cervical

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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CPT Code Cervical Artificial Disc – Two Levels:

Revision including replacement of total disc arthroplasty, anterior approach, single 22861 interspace; cervical

22864 Removal of total disc arthroplasty, anterior approach, single interspace; cervical

Revision including replacement of total disc arthroplasty, anterior approach, each +0098T additional interspace, cervical

Removal of total disc arthroplasty, anterior approach, each additional interspace, +0095T cervical

CPT Code Cervical Posterior Decompression (without fusion): Laminectomy with exploration and/or decompression of spinal cord and/or cauda 63001 equina, without facetectomy, foraminotomy or discectomy, 1 or 2 vertebral segments; cervical Laminectomy with exploration and/or decompression of spinal cord and/or cauda 63015 equina, without facetectomy, foraminotomy or discectomy, more than 2 vertebral segments; cervical Laminotomy, with decompression of nerve root(s), including partial facetectomy, 63020 foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical Laminotomy, with decompression of nerve root(s), including partial facetectomy, 63040 foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical Laminectomy, facetectomy and foraminotomy, (unilateral or bilateral with 63045 decompression of spinal cord, cauda equine and/or nerve root[s]. [e.g., spinal or lateral recess stenosis]), single vertebral segment; cervical , cervical, with decompression of the spinal cord, 2 or more vertebral 63050 segments;

Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral 63051 segments; with reconstruction of the posterior bony elements Laminotomy, with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional +63035 interspace, cervical or lumbar (List separately in addition to code for primary procedure). Code first (63020-63030) Laminotomy, with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single +63043 interspace; each additional cervical interspace. (List separately in addition to code for primary procedure). Code first (63040) Laminectomy, facetectomy and foraminotomy, (unilateral or bilateral with decompression of spinal cord, cauda equine and/or nerve root[s]. [e.g., spinal or +63048 lateral recess stenosis]), (single vertebral segment; each additional segment, cervical, thoracic, or lumbar (Code first (63045-63047). (List separately in addition to code for primary procedure)

CPT Code Cervical Anterior Decompression (without fusion):

Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), 63075 including osteophytectomy; cervical, single interspace

Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), +63076 including osteophytectomy; cervical, each additional interspace. (List separately in addition to code for primary procedure) Code first (63075).

Additional Procedures Codes: • Vertebral Corpectomy: 63081, +63082, 63300, 63304, +63308

Reviewed by / Approval Signatures

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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Clinical Quality & Utilization Mgmt. Committee: Norman White MD Medical Director: David Yu MD Date Approved: 05/26/2021

References

1. NIA Magellan, Lumbar Spinal Fusion Surgery, Lumbar Decompression Procedures, Lumbar Microdisectomy Only Procedure, Guideline Number: NIA_CG_304, last revised date: Oct 2020. Accessed 04/12/2021 2. CMS, National Coverage Determination (NCD) for Breast Reconstruction Following, Mastectomy (140.2), Version 1, effective date 01/01/1997. [Cited 04/12/2021]. 3. NIA Magellan, CERVICAL SPINE SURGERY, Guideline Number: NIA_CG_307, last revised date: Nov 2020. Accessed 04/12/2021 4. Magellan Clinical Guidelines for Medical Necessity Review. Accessed 04/12/2021.

Publication History

07-27.16: Annual Review. Change to NIA Magellan Lumbar Spine Surgery criteria available on the RAD MD website 01-24-18: Annual Review. See NIA Magellan criteria on RAD MD website 09-26-18: The following Medical Policies were merged into this policy: • Artificial Disc Replacement MPM 1.3 • Lumbar Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy, MPM 12.0 • Lumbar Fusion (Arthrodesis), MPM 12.1 01-22-10: Annual Review. No change to content. Web links updated. CQUMC approved NIA Magellan criteria July 31, 2019 05-22-20: Review the annual renewal of 2020-2021 NIA Magellan clinical guidelines used for Musculoskeletal Program. The changes go into effect on July 1, 2020. Medical Policy Committee found no changes to the agreed upon procedures 05-26-21: Annual review. Reviewed by PHP Medical Policy Committee on 05/05/2021. No criteria change, will resume purchased criteria for NIA approved by CQUMC on 03/24/21. The NIA Magellan clinical guidelines and PHP/NIA Magellan Matrix) were reviewed and the following CPT codes were updated: Remove language in the PA “deny codes: 22858 and 0098T (Cervical Artificial Disc - Two Levels) as ‘investigational’ in the PA grid”. These codes are on the Matrix as covered and is also listed in the clinical guideline of NIA Magellan. Delete/remove 0375T from PA, since AMA deleted the code on 01/01/2020. New CPT codes added to policy: Vertebral Corpectomy: 63081, +63082, 63300, 63304, +63308. Non-covered LADR (including revision) codes 22857, 22862, 22865 and its related add-on codes 0163T, 0634T and 0165T are considered investigational for all LOB and will be configured to not pay and place these codes in the Investigational List MPM 36.0.

This Medical Policy is intended to represent clinical guidelines describing medical appropriateness and is developed to assist Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) Health Services staff and Presbyterian medical directors in determination of coverage. The Medical Policy is not a treatment guide and should not be used as such. For those instances where a member does not meet the criteria described in these guidelines, additional information supporting medical necessity is welcome and may be utilized by the medical director in reviewing the case. Please note that all Presbyterian Medical Policies are available online at: Click here for Medical Policies

Web links: At any time during your visit to this policy and find the source material web links has been updated, retired or superseded, PHP is not responsible for the continued viability of websites listed in this policy.

When PHP follows a particular guideline such as LCDs, NCDs, MCG, NCCN etc., for the purposes of determining coverage; it is expected providers maintain or have access to appropriate documentation when requested to support coverage. See the References section to view the source materials used to develop this resource document.

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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