Cover Spine Surgery Guidelines Musculoskeletal Program Clinical Appropriateness Guidelines Spine Surgery EFFECTIVE JULY 01, 2018 LAST REVIEWED DECEMBER 12, 2017 Appropriate.Safe.Affordable © 2018 AIM Specialty Health 2063-0718 V.2 Table of Contents Description and Application of the Guidelines ...................................................................................................................... 4 Cervical Decompression With or Without Fusion .................................................................................................................. 5 Description ..................................................................................................................................................................................................... 5 Definitions ...................................................................................................................................................................................................... 6 Criteria............................................................................................................................................................................................................ 7 Exclusions ...................................................................................................................................................................................................... 8 Selected References ..................................................................................................................................................................................... 9 CPT Codes ...................................................................................................................................................................................................... 9 History .......................................................................................................................................................................................................... 11 Cervical Disc Arthroplasty .................................................................................................................................................... 12 Description ................................................................................................................................................................................................... 12 Definitions .................................................................................................................................................................................................... 12 Criteria.......................................................................................................................................................................................................... 13 Contraindications ........................................................................................................................................................................................ 13 Exclusions .................................................................................................................................................................................................... 14 Selected References ................................................................................................................................................................................... 14 CPT Codes .................................................................................................................................................................................................... 14 History .......................................................................................................................................................................................................... 15 Lumbar Disc Arthroplasty .................................................................................................................................................... 16 Description ................................................................................................................................................................................................... 16 Definitions .................................................................................................................................................................................................... 16 Criteria.......................................................................................................................................................................................................... 17 Contraindications ........................................................................................................................................................................................ 17 Exclusions .................................................................................................................................................................................................... 18 Selected References ................................................................................................................................................................................... 18 CPT Codes .................................................................................................................................................................................................... 18 History .......................................................................................................................................................................................................... 18 Lumbar Discectomy, Foraminotomy, and Laminotomy ....................................................................................................... 19 Description ................................................................................................................................................................................................... 19 Definitions .................................................................................................................................................................................................... 19 Criteria.......................................................................................................................................................................................................... 20 Exclusions .................................................................................................................................................................................................... 20 Selected References ................................................................................................................................................................................... 21 CPT Codes .................................................................................................................................................................................................... 21 History .......................................................................................................................................................................................................... 21 Lumbar Fusion and Treatment of Spinal Deformity (including Scoliosis and Kyphosis) ..................................................... 22 Description ................................................................................................................................................................................................... 22 General Considerations ............................................................................................................................................................................... 22 Definitions .................................................................................................................................................................................................... 23 Criteria.......................................................................................................................................................................................................... 24 Exclusions .................................................................................................................................................................................................... 26 Copyright © 2018. AIM Specialty Health. All Rights Reserved. Spine Surgery 2 Selected References ................................................................................................................................................................................... 26 CPT Codes .................................................................................................................................................................................................... 27 History .......................................................................................................................................................................................................... 30 Lumbar Laminectomy ......................................................................................................................................................... 31 Description ..................................................................................................................................................................................................