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Spinal Fusion, Lumbar These Services May Or May Not Be Covered by Your Healthpartners Plan

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Spinal Fusion, Lumbar These Services May Or May Not Be Covered by Your Healthpartners Plan 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 documents will be used to determine your coverage. Administrative Process Prior authorization is required for lumbar spine fusion surgery for degenerative spine conditions for members age 18 and older. Prior authorization is not required for lumbar fusion surgery for members under the age of 18. Prior authorization is not required for fusion surgery of the cervical and thoracic areas of the spine for members of any age. Prior authorization is generally not required for the type of access and associated instrumentation. Exceptions to this are noted in the Indications Not Covered Section. The Designated Medical Spine Center (MSC) 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. Coverage Lumbar spinal fusion surgery is covered per the indications listed below. For the purpose of this policy, anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion and minimally invasive transforaminal lumbar interbody fusion (TLIF/MI-TLIF) and posterolateral gutter fusion, via open incision, are considered standard approaches. The following lateral approaches are considered equivalent to standard approaches: oblique lateral interbody fusion (OLIF), extreme lateral interbody fusion (XLIF) and direct lateral fusion (DLIF) Standard spinal instrumentation or visualization technology is considered covered when all coverage criteria are met. The patient is to be offered patient decision support. Indications that are covered without prior authorization Lumbar fusions are considered medically necessary for spinal instability associated with any of the following conditions, see also a partial list of ICD-10-CM codes that do not require prior authorization at the end of this document: • Epidural compression or vertebral destruction from tumor • Idiopathic scoliosis • Instability after debridement for infection • Neural compression after spinal fracture • Pseudarthrosis • Spinal infections (including tuberculosis, osteomyelitis, discitis) • Acute cauda equine 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 Non-emergent lumbar spinal fusion is covered when the following criteria are met: 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; and 2. The visit summary notes from the MSC must be submitted with the request; and 3. Documentation by the operating surgeon demonstrating compliance with all the following criteria: A. Severe pain and disability limiting activities of daily living despite at least 8 weeks of intensive conservative treatments (such as exercise, activity modification or chiropractic care). Documentation of conservative treatments must correspond to the current episode of pain (within 6 months). o Conservative treatments must include physical therapy (PT), at least 4 visits over a course of 6 weeks or less. Active muscle conditioning is required as part of physical therapy. o Physical therapist’s notes must be submitted, or there must be a physician’s statement in the clinical documents that explains why physical therapy is contraindicated. o If a member is unable to complete physical therapy due to progressively worsening pain and disability, documentation in the physical therapists notes demonstrating this is required. The requirement for physical therapy will not be met if there is a failure to complete prescribed physical therapy for non-clinical reasons. B. A preoperative ODI that is greater than 40% or FOTO Status Score that is 21 – 60; C. A statement documenting the absence of untreated, underlying mental health conditions (including but not limited to psychological conditions or drug or alcohol abuse) that may be a contributor to the individual’s chronic back pain, D. For only the clinical situations listed in i. -iii. below, a 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. The intent of the evaluation is to include assessment such as the ability of the individual to understand the risks and realistic outcomes for the procedure and to comply with any behavioral changes as needed post-surgery, and also to document the absence of untreated mental illness contributing to chronic pain. The evaluation is required only in the following situations: i. Preoperative ODI score is 80% or higher, or a FOTO score less than 2; or ii. Lumbar fusion for treatment of chronic discogenic pain alone (degenerative disc disease without instability or deformity) or iii. Lumbar fusion for post-laminectomy/failed back surgery syndrome and 4. Fusion surgery is for treatment of chronic (defined as lasting equal to or longer than one year) discogenic back pain alone (degenerative disc disease without instability or deformity) with documented unremitting, discogenic pain and disability for at least 1 year; or 5. Fusion surgery is for treatment of a degenerative condition with spinal instability or spinal stenosis with documented unremitting pain and disability for at least 3 months associated with one or more of the following diagnoses: A. Spondylolisthesis; B. Spinal stenosis; C. Spinal stenosis when planned decompressive laminectomy surgery is likely to result in iatrogenic instability (greater than 50% facet joint excision bilaterally or entire facet on one side) D. Scoliosis (degenerative); E. Post laminectomy syndrome; or F. Progressive objective neurological deficit. 6. Confirmatory radiographic documentation (plain radiographs, advanced imaging studies), supporting the indication for the fusion surgery. Lumbar fusion for degenerative conditions, as listed under criterion 5 above, must provide documentation of spinal instability. The use of recombinant human bone morphogenetic protein (rhBMP) 2 for lumbar fusion in adult patients is covered when criteria for the fusion are met and use is not outside of the following guidelines: 1. Performed for treatment of degenerative disc disease; 2. No more than Grade I spondylolisthesis at the involved level; 3. Fusion is for one level only from L2-S1 via open anterior approach; 4. Member has had inadequate response to at least 6 months of prior nonoperative treatment; 5. 1Member has inadequate autograft or contraindications to harvesting of bone autograft, provided that the member is skeletally mature; 6. There are no contraindications to rhBMP. Indications that are not covered Lumbar fusions are not considered medically necessary or covered for the management of the following situations: 1. With initial primary laminectomy/discectomy for nerve root decompression without documented instability; 2. Degenerative disc disease without documented spinal instability or spinal deformity, when involving three or more levels. 3. Absence of an evaluation at a Designated Medical Spine Center (MSC), when a MSC visit is required per the Spine surgical practice - low back pain office visits policy; and 4. 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: 1. Anterior interbody fusion or implantation of intervertebral body fusion devices using a laparoscopic approach (LALIF) or (lap-ALIF) 2. Axial interbody approach (AxiaLif) 3. Dynamic spine stabilization device systems (Including but not limited to Dynesys Stabilization System, Zimmer DTO implant, Coflex Interlaminar stabilization device) 4. Interlaminar lumbar instrumented fusion (ILIF) 5. Interspinous fixation device (IFD) (examples include, but are not limited to, Aspen™, Coflex-F®, Minuteman® fusion plate, Medtronic CD Horizon Spire ™) as adjunct to fusion or as stand-alone procedure. 6. Minimally invasive fusion approaches using only indirect visualization (surgeon does not have visualization of the surgical site with the naked eye). This would include endoscopic fusion and percutaneous fusion techniques using video or fluoroscopic imaging alone. An example includes, but is not limited to, Oblique Lateral Lumbar Interbody Fusion (OLLIF). 7. The requested procedure includes the combined use of an artificial intervertebral disc and spinal fusion surgery (i.e. hybrid surgery) Definitions Cauda equina syndrome – The cauda equina is a bundle of spinal nerve roots which spread out from the bottom of the spinal cord. Cauda equina syndrome is a group of symptoms that may happen if the cauda equina gets squeezed or damaged. The symptoms may include pain, numbness and weakness in the lower back and legs, foot drop, and problems controlling the bowels or bladder. Designated Medical
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