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Policy 201208: Lumbar Spinal Fusion

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Policy 201208: Lumbar Spinal Fusion Policy: 201208 Initial Effective Date: 01/01/2013 SUBJECT: Lumbar Spinal Fusion Annual Review Date: 04/25/2018 Last Revised Date: 011/02/2020 Prior approval is required for some or all procedure codes listed in this Corporate Medical Policy. Some or all procedure codes listed in this Corporate Medical Policy may be considered experimental/investigational. Definition: Lumbar spinal fusion (interbody fusion, lumbar arthrodesis) is the surgical immobilization (fixation) of two or more adjacent vertebral bodies of the lumbar spine. Although decreased spinal flexibility may result, vertebral fusion is designed to alleviate pain, improve function, restore stability and produce a more anatomically correct vertebral alignment. Conditions that may require lumbar spinal fusion include, but are not limited to: spinal instability, spinal stenosis, spinal cord compression and vertebral destruction caused by infection and tumors. Several surgical approaches and techniques exist in treatment of spinal conditions. Minimally invasive approaches and devices, e.g., Anterior Lumbar Interbody Fusion (ALIF®), Axial Lumbar Interbody Fusion (AxiaLIF, TranS1®), Direct Lateral Interbody Fusion (DLIF), Extreme Lateral Interbody Fusion (XLIF), Maximal Access Surgery® MAS Interlaminar Lumbar Instrumented Fusion (ILIF™) (e.g., Coflex-F® Implant System), Laparoscopic Anterior Lumbar Interbody Fusion (LALIF), Posterior Lumbar Interbody Fusion (PLIF), Posterior Lumbar Intertransverse Process Fusion (PLIT), Transforaminal Lumbar Interbody Fusion (TLIF), Dynamic Spine Stabilization Device Systems (e.g., Dynesys®, Stabilimax NZ®) and Total Facet Arthroplasty (e.g., Total Facet Arthroplasty System™, SPIRE™ Stabilization System) can also be utilized as an alternative to or part of spinal fusion surgery. Medical Necessity: The Company considers lumbar spinal fusion (CPT 22533, 22534, 22558, 22585, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22808, 22840, 22845, 22853, 22854, 22859 and applicable ICD-10-CM Procedure Codes) medically necessary and eligible for reimbursement providing at least one of the following medical criteria is met: • Radiographic evidence (e.g., x-ray, computed tomography scan, magnetic resonance imaging) of lumbar spinal instability and at least one of the following: 1. Acute spinal fracture; or 2. Progressive neurological impairment (e.g., increasing weakness, bladder instability); or 3. Neural compression after spinal fracture; or 4. Epidural compression or vertebral destruction from tumor; or This document is subject to the disclaimer found at http://www.medmutual.com/provider/MedPolicies/Disclaimer.aspx. If printed, this document is subject to change. Always verify with the most current version of the official document at http://www.medmutual.com/provider/MedPolicies/Disclaimer.aspx. © 2014 Medical Mutual of Ohio Policy #201208 ~ Page 1 of 9 5. Spinal tuberculosis; or 6. Spinal debridement following infection (e.g., osteomyelitis); or 7. Spinal deformity (e.g., idiopathic scoliosis >40°, progressive degenerative scoliosis); OR • Spinal stenosis and associated spondylolisthesis with radiographic evidence (e.g., x-ray, computed tomography scan, magnetic resonance imaging) of instability and all of the following: 1. Back pain with neurogenic claudication or radicular pain; and 2. Continued significant functional impairment despite ≥3 months of conventional medical therapy, including trials of all of the following (unless contraindicated): a. Anti-inflammatory medications; and b. Analgesics; and c. Supervised physical therapy program; and d. Daily exercise routine; and e. Lifestyle activity modification (e.g., weight loss program); and 3. Individual must agree to discontinue smoking for six weeks before and six weeks after surgery unless surgery is urgent or emergent; OR • Radiographic evidence (e.g., x-ray, computed tomography scan, magnetic resonance imaging) of spondylolisthesis and all of the following: 1. Symptoms and signs of neurological compromise are clinically associated with this area of spondylolisthesis; and 2. Spondylolisthesis-associated pain and significant functional impairment despite >3 months of conventional medical therapy, including trials of all of the following (unless contraindicated): a. Anti-inflammatory medications; and b. Analgesics; and c. Supervised physical therapy program; and d. Daily exercise routine; and e. Lifestyle activity modification (e.g., weight loss program); and 3. Individual must agree to discontinue smoking for six weeks before and six weeks after surgery unless surgery is urgent or emergent; OR This document is subject to the disclaimer found at http://www.medmutual.com/provider/MedPolicies/Disclaimer.aspx. If printed, this document is subject to change. Always verify with the most current version of the official document at http://www.medmutual.com/provider/MedPolicies/Disclaimer.aspx. © 2014 Medical Mutual of Ohio Policy #201208 ~ Page 2 of 9 • Radiographic evidence (e.g., computed tomography scan, magnetic resonance imaging or discography) of single level degenerative disc disease without instability and all of the following: 1. Chronic, unrelenting pain likely caused by a degenerated disc despite >6 months of conventional medical therapy, including trials of all of the following (unless contraindicated): a. Anti-inflammatory medications; and b. Analgesics; and c. Supervised, structured physical therapy program; and d. Daily exercise routine; and e. Lifestyle activity modification (e.g., weight loss program); and 2. Individual must agree to discontinue smoking for six weeks before and six weeks after surgery unless surgery is urgent or emergent; and 3. Degenerative disc disease at the targeted level has been documented by the treating physician to be responsible for significant, definable functional impairment and chronic pain; and 4. Degenerative disc disease is confined to a single lumbar disc; OR • Post-lumbar spinal surgery (≥3 months previously) recurrent disc herniation and all of the following: 1. Symptoms and signs of neurological compromise are clinically associated with recurrent disc herniation; and 2. Significant functional impairment; and 3. Neural compression and/or instability confirmed by recent radiographic imaging (e.g., x-ray, computed tomography scan, magnetic resonance imaging); and 4. Worsening neurological function despite >3 months of conventional medical therapy, including trials of all of the following (unless contraindicated): a. Anti-inflammatory medications; and b. Analgesics; and c. Supervised physical therapy program; and d. Daily exercise routine; and e. Lifestyle activity modification (e.g., weight loss program); and 5. Individual must agree to discontinue smoking for six weeks before and six weeks after surgery unless surgery is urgent or emergent; OR This document is subject to the disclaimer found at http://www.medmutual.com/provider/MedPolicies/Disclaimer.aspx. If printed, this document is subject to change. Always verify with the most current version of the official document at http://www.medmutual.com/provider/MedPolicies/Disclaimer.aspx. © 2014 Medical Mutual of Ohio Policy #201208 ~ Page 3 of 9 • Radiographic evidence (e.g., computed tomography scan, magnetic resonance imaging or discography) of adjacent degenerative disc disease and all of the following: 1. Chronic, unrelenting pain likely caused by an adjacent degenerated disc despite ≥6 months of conventional medical therapy, including trials of all of the following (unless contraindicated): a. Anti-inflammatory medications; and b. Analgesics; and c. Supervised physical therapy program; and d. Daily exercise routine; and e. Lifestyle activity modification (e.g., weight loss program); and 2. Individual must agree to discontinue smoking for six weeks before and six weeks after surgery unless surgery is urgent or emergent; and 3. Adjacent degenerated disc disease has produced significant definable functional impairment; and 4. Postoperative lumbar spinal surgery (≥6 months previously); OR • Pseudoarthrosis (non-union of prior attempted vertebrae fusion) ≥6 months since previous surgery and all of the following: 1. Radiographic evidence (e.g., x-ray, computed tomography scan, magnetic resonance imaging) of non- union; and 2. Prior surgery resulted in relief of some pain symptoms; and 3. Worsening neurological function despite >3 months of conventional medical therapy, including trials of all of the following (unless contraindicated): a. Anti-inflammatory medications; and b. Analgesics; and c. Supervised physical therapy program; and d. Daily exercise routine; and e. Lifestyle activity modification (e.g., weight loss program); and 4. Individual must agree to discontinue smoking for six weeks before and six weeks after surgery unless surgery is urgent or emergent; AND At least one of the following clinical conditions is present: • Tuberculoma of spinal cord, unspecified This document is subject to the disclaimer found at http://www.medmutual.com/provider/MedPolicies/Disclaimer.aspx. If printed, this document is subject to change. Always verify with the most current version of the official document at http://www.medmutual.com/provider/MedPolicies/Disclaimer.aspx. © 2014 Medical Mutual of Ohio Policy #201208 ~ Page 4 of 9 • Tuberculous abscess of spinal cord • Malignant neoplasm of vertebral column, excluding sacrum and coccyx • Malignant neoplasm of spinal meninges • Secondary malignant neoplasm of brain and spinal cord • Secondary malignant neoplasm of other parts of the nervous system • Secondary
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