Spine Surgery Guidelines Musculoskeletal Program Clinical Appropriateness Guidelines Spine Surgery EFFECTIVE JANUARY 01, 2019 LAST REVIEWED SEPTEMBER 12, 2018 Appropriate.Safe.Affordable © 2019 AIM Specialty Health 2063-0119 V.3 Table of Contents Spine Surgery Guidelines ...................................................................................................................................................... 1 Description and Application of the Guidelines ...................................................................................................................... 4 Cervical Decompression With or Without Fusion .................................................................................................................. 5 Description ............................................................................................................................................................................. 5 General Requirements .......................................................................................................................................................... 6 Criteria .................................................................................................................................................................................... 7 Exclusions .............................................................................................................................................................................. 9 Selected References ............................................................................................................................................................. 9 CPT Codes .............................................................................................................................................................................. 9 History .................................................................................................................................................................................. 12 Cervical Disc Arthroplasty .................................................................................................................................................... 13 Description ........................................................................................................................................................................... 13 General Requirements ........................................................................................................................................................ 13 Criteria .................................................................................................................................................................................. 14 Contraindications ................................................................................................................................................................. 14 Exclusions ............................................................................................................................................................................ 15 Selected References ........................................................................................................................................................... 15 CPT Codes ............................................................................................................................................................................ 15 History .................................................................................................................................................................................. 16 Lumbar Disc Arthroplasty .................................................................................................................................................... 17 Description ........................................................................................................................................................................... 17 General Requirements ........................................................................................................................................................ 17 Criteria .................................................................................................................................................................................. 18 Contraindications ................................................................................................................................................................. 18 Exclusions ............................................................................................................................................................................ 19 Selected References ........................................................................................................................................................... 19 CPT Codes ............................................................................................................................................................................ 19 History .................................................................................................................................................................................. 19 Lumbar Discectomy, Foraminotomy, and Laminotomy ....................................................................................................... 20 Description ........................................................................................................................................................................... 20 General Requirements ........................................................................................................................................................ 20 Criteria .................................................................................................................................................................................. 21 Exclusions ............................................................................................................................................................................ 21 Selected References ........................................................................................................................................................... 22 CPT Codes ............................................................................................................................................................................ 22 History .................................................................................................................................................................................. 22 Lumbar Fusion and Treatment of Spinal Deformity (including Scoliosis and Kyphosis) ..................................................... 23 Description ........................................................................................................................................................................... 23 General Considerations and Requirements ....................................................................................................................... 23 Criteria .................................................................................................................................................................................. 25 Copyright © 2019. AIM Specialty Health. All Rights Reserved. Spine Surgery 2 Exclusions ............................................................................................................................................................................ 27 Selected References ........................................................................................................................................................... 27 CPT Codes ............................................................................................................................................................................ 28 History .................................................................................................................................................................................. 30 Lumbar Laminectomy ......................................................................................................................................................... 31 Description ........................................................................................................................................................................... 31 General Requirements ........................................................................................................................................................ 31 Criteria .................................................................................................................................................................................. 32 Exclusions ............................................................................................................................................................................ 32 Selected References ........................................................................................................................................................... 33 CPT Codes ...........................................................................................................................................................................