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Evicore Lumbar Spinal Fusion Clinical Guidelines

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Evicore Lumbar Spinal Fusion Clinical Guidelines CLINICAL GUIDELINES BlueCross BlueShield of Kansas City Lumbar Spine Fusion Effective July 1, 2013 (Reviewed January 1, 2019) Clinical guidelines for medical necessity review of spine surgery. © 2019 eviCore healthcare. All rights reserved. Musculoskeletal Benefit Management Program: Lumbar Spine Fusion V1.0.2019 ____________________________________________________________________________ 2019 LUMBAR SPINE: FUSION GUIDELINES LSF-1: INTRODUCTION AND GENERAL GUIDELINES 3 LSF-2: INSTABILITY 6 LSF-3: DEGENERATIVE DISORDERS OF THE SPINE 8 LSF-4: SPONDYLOLYSIS & SPONDYLOLISTHESIS 10 LSF-5: STENOSIS 12 LSF-6: PRIOR LUMBAR SPINE SURGERY 14 LSF-7: DEFORMITY 18 LSF-8: TRAUMA 20 LSF-9: NEOPLASTIC DISORDERS 22 LSF-10: INFECTION 23 LSF-11: APPENDIX - DEVICES 25 LSF-12: APPENDIX - ABBREVIATIONS 26 LSF-13: APPENDIX - GLOSSARY 27 LSF-14: APPENDIX – CPT® CODES 28 LSF-15: APPENDIX – SUPPORTING LITERATURE 29 LSF-16: APPENDIX – PROCEDURE DEFINTIONS 34 ____________________________________________________________________________ © 2019 eviCore healthcare. All rights reserved. Page 2 of 35 400 Buckwalter Place Boulevard, Bluffton, SC 29910 • (800) 918-8924 www.eviCore.com Musculoskeletal Benefit Management Program: Lumbar Spine Fusion V1.0.2019 ____________________________________________________________________________ LUMBAR SPINE: FUSION GUIDELINES LSF-1: INTRODUCTION AND GENERAL GUIDELINES LSF-1.1: Introduction These guidelines address lumbar spine fusion (LSF) procedures and/or devices for the adult patient population 18 years of age and older. Both spinal conditions and procedural approaches and devices are described for their appropriateness and coverage. Accepted indications for lumbar spinal fusion procedures and/or devices based primarily on appropriate supportive medical evidence will be addressed in condition specific sections outlined below. Those procedures and/or devices described as “not indicated” are based on a lack of a significant body of medical evidence supporting their efficacy. The indications for lumbar spinal fusion will be further examined in the following condition-specific sections, which include: Degenerative Disorders Spondylolysis & Spondylolisthesis Stenosis Prior Lumbar Spine Surgery Deformity Trauma Neoplastic Disease Infection ____________________________________________________________________________ © 2019 eviCore healthcare. All rights reserved. Page 3 of 35 400 Buckwalter Place Boulevard, Bluffton, SC 29910 • (800) 918-8924 www.eviCore.com Musculoskeletal Benefit Management Program: Lumbar Spine Fusion V1.0.2019 ____________________________________________________________________________ LSF -1.2: Tenets of Lumbar Spine Fusion Surgery: General Requirements The table below represents the essential documentation of conditions and evaluations that should be received prior to any considerations for all lumbar spine fusion procedures (exceptions as noted). All subsequent guidelines and indications in this document will reference these general requirements. Requirement Details Diagnosis and rational for fusion NA Lifestyle modifications, weight loss, nicotine cessation, medications, nonsteroidal anti-inflammatory medications, Non-operative care physical therapy, medical exercise, bracing, spinal manipulation, epidural steroid injections (when indicated), behavioral therapy, etc. Relative contraindications to spinal fusion include the following: Osteoporosis Relative contraindications to Smoking spine fusion, to be weighed Malnutrition against the risks of not Systemic infection performing surgery Anemia Chronic hypoxemia Severe cardiopulmonary disease Severe depression, psychosocial issues, and secondary gain issues Recent history & examination in Detailed neurological exam relevant to fusion request Bowel/bladder abnormalities the preceding 6 weeks Motor deficits defined by location 0= No evidence of muscle function 1= Muscle contraction but no or very limited joint motion (“trace”) Grading of manual muscle 2=Complete range of motion with gravity eliminated testing in the preceding 6 weeks (“poor”) 3=Complete range of motion against gravity (“fair”) 4=Complete range of motion against gravity with some resistance (“good”) 5=Complete range of motion against gravity with full or normal resistance (“normal”) Continued next page . ____________________________________________________________________________ © 2019 eviCore healthcare. All rights reserved. Page 4 of 35 400 Buckwalter Place Boulevard, Bluffton, SC 29910 • (800) 918-8924 www.eviCore.com Musculoskeletal Benefit Management Program: Lumbar Spine Fusion V1.0.2019 ____________________________________________________________________________ LSF -1.2: Tenets of Lumbar Spine Fusion Surgery: General Requirements Table continued . Requirement Details Plain lumbar x-rays (as indicated) Lumbar flexion/extension x-rays (as indicated) Lumbar bending films (as indicated) Advanced imaging (as indicated) All relevant imaging studies o Lumbar MRI o Lumbar CT o Lu mbar CT/Myelography o Lumbar CT/Discography Other imaging studies (as indicated) Psych evaluations, including The “Waddell Test” is a screening tool for to assess for “Waddell’s Test” psychological factors (nonorganic findings) when evaluating for back pain. Nicotine cessation 4 to 8 weeks Patient attempts nicotine cessation prior to fusion, and until prior fusion has consolidated LSF-1.3: Exceptions: Exceptions considered on a case by case basis. LSF-1.4: References 1. Brox JI et al. (2003). Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine, 28: p. 1913-1921. 2. Mirza SK, Deyo RA. Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine 2007;32:816-823. 3. Orthopaedic Knowledge Update Spine 4, AAOS, 2012. ____________________________________________________________________________ © 2019 eviCore healthcare. All rights reserved. Page 5 of 35 400 Buckwalter Place Boulevard, Bluffton, SC 29910 • (800) 918-8924 www.eviCore.com Musculoskeletal Benefit Management Program: Lumbar Spine Fusion V1.0.2019 ____________________________________________________________________________ LUMBAR SPINE: FUSION GUIDELINES LSF-2: INSTABILITY LSF-2.1: Background The stable spine is recognized as having normal sagittal and coronal plane alignment without evidence of imbalance. For the stable spine, there is no evidence on imaging of abnormal segmental alignment such as intersegmental translation, angulation, or subluxation, either at rest or with motion. By contrast, there is no agreed upon definition for spine instability. Generally, instability refers to a loss of spinal integrity to withstand physiologic loads or stresses resulting in increased or abnormal motion between vertebral motion segments that result in pain, deformity and/or neurologic compromise, and/or significant angular and/or rotational and/or translational changes in the spine. Diagnostic checklists are often used to diagnose spinal instability including, White and Panjabi's classification, Holdsworth's two- column theory, and Denis’ three-column theory; however, documentation of these checklists is not required for consideration of fusion surgery. Ultimately, instability may be the result of a variety of spine conditions and can result in pain, deformity and/or neurologic compromise. Despite lack of an agreed upon clinical definition, instability is generally accepted as the underlying primary indication for a lumbar spinal fusion procedure. LSF-2.2: Indicated Instability from angular and translational changes in the spine Instability from spondylolisthesis as defined below under LSF-4 Instability from deformity as defined below under LSF-7 Instability from trauma as defined below under LSF-8 Instability from neoplastic disorders as defined below under LSF-9 Instability from infection as defined below under LSF-10 Instability resulting in neuroforaminal stenosis with neurologic compression Instability created surgically: ____________________________________________________________________________ © 2019 eviCore healthcare. All rights reserved. Page 6 of 35 400 Buckwalter Place Boulevard, Bluffton, SC 29910 • (800) 918-8924 www.eviCore.com Musculoskeletal Benefit Management Program: Lumbar Spine Fusion V1.0.2019 ____________________________________________________________________________ o Unilateral facetectomy o Bilateral partial facetectomy of 50% or greater o Pars resection or fracture o Corpectomy and vertebrectomy o Any other decompressive procedures known to cause instability o Adjacent Segment Disease (ASD) associated with clinically symptomatic spinal stenosis LSF-2.3: Not Indicated Initial routine laminectomy without instability Initial routine hemilaminectomy, partial laminectomy, laminotomy or foraminotomy without instability Initial routine discectomy without instability, single or multiple levels LSF-2.4: References 1. Posner I, White AA 3rd, Edwards WT, Hayes WC. A biomechanical analysis of the clinical stability of the lumbar and lumbosacral spine. Spine 1982; 7:374–389. 2. Leone A, Guglielmi G, et al. (2007). Lumbar Intervertebral Instability: A Review. Radiology, 245:62-77. 3. Orthopaedic Knowledge Update Spine 4, AAOS, 2012. 4. Hu SS, Tribus CB, Tay BK, Bhatia NN. Chapter 5. Disorders, Diseases, & Injuries of the Spine. In: Skinner HB, ed. CURRENT Diagnosis & Treatment in Orthopedics. 4th Ed. New York: McGraw-Hill;
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