Spinal fusion, lumbar

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1 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. Prior authorization is not required for fusion surgery of the cervical and thoracic areas of the spine. 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 (TLIF/MITLIF) and posterolateral gutter fusion, via open incision, are considered standard approaches. Lateral approaches such as oblique lateral interbody fusion (OLIF), extreme lateral interbody fusion (XLIF) and direct lateral fusion (DLIF) are considered equivalent to the standard approaches. Standard spinal instrumentation or visualization technology is considered covered when all of the coverage criteria are met. Variations in the type of technology have not shown a difference in clinical outcomes. The patient is to be offered patient decision support. This policy addresses the adult population. Spinal fusion surgery for children will be addressed on a case by case basis. Indications that are covered without prior authorization Lumbar fusions are considered medically necessary for spinal instability associated with any of the following conditions: Epidural compression or vertebral destruction from tumor Idiopathic scoliosis over 40 degrees 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 Page 1 of 7

2 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 of the following criteria: A. Documented unremitting pain and disability that is refractory to intensive conservative therapy for at least 8 weeks. The course of intensive therapy must include all of the following: i. An active, organized, and progressive strength and flexibility program; Conservative therapy must include physical therapy (PT) and may include activity modification, weight loss, and drug therapy. Documentation must correspond to the current episode of pain (within 6 months).formal physical therapy, at least four visits over a six week course, including active muscle conditioning is required, or there must be an explicit statement in the clinical documents that explains why such physical therapy is contraindicated. The requirement for physical therapy will not be met if there is a failure to complete prescribed physical therapy for non-clinical reasons. Documentation of formal physical therapy would be the therapist s notes. If a patient is unable to complete physical therapy (PT) due to progressively, worsening pain and disability, the case will be reviewed on an individual basis by an internal physician reviewer. Documentation in the physical therapist s notes demonstrating this must be submitted; and ii. A psycho-educational component that deals with patient expectations and perceptions as well as the anatomic sources of back pain; and iii. Documentation of less than 30% improvement in the Oswestry Disability Index (ODI) or Focus On Therapeutic Outcomes (FOTO) scores between starting conservative treatment and the day a decision to have surgery is made; and iv. A preoperative ODI that is still between 40% - 79% or FOTO Status Score that is still 21 60; and B. Absence of untreated, underlying, contributory mental health conditions or psychological issues (including but not limited to depression, drug or alcohol abuse); and 4. Fusion surgery is for treatment of chronic (defined as lasting equal to or longer than one year) discogenic back pain alone (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 decompression 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. Lumbar fusion for degenerative conditions must also provide radiographic documentation (plain radiographs, MRI/CT scans) of spinal instability. If the preoperative ODI score is greater than 80% or the FOTO score is less than 20, then 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 is required. Lumbar fusion for treatment of chronic discogenic pain or post laminectomy syndrome must have 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 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. Member 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 conditions: With initial primary laminectomy/discectomy for nerve root decompression without documented instability; Page 2 of 7

3 Multiple-level degenerative disc disease (more than 2 disc levels); Minimally invasive facet fusions; Absence of an evaluation at a Designated Medical Spine Center; and 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: Anterior interbody fusion or implantation of intervertebral body fusion devices using a laparoscopic approach (LALIF) or (lap-alif); Axial interbody approach (AxiaLif); Dynamic spine stabilization device systems (e.g., Dynesys, Stabilimax NZ); Interspinous Process Decompression (IPD) systems (e.g., X-STOP); Stand alone Spire plate for fusion Interlaminar lumbar instrumented fusion (ILIF) Definitions Anterior lumbar spine surgery is performed by approaching the spine from the front of the body using a traditional front midline incision (i.e., through the abdominal musculature and retroperitoneal cavity) or by lateral approaches from the front side of the body (e.g., extreme lateral interbody fusion [XLIF]; direct interbody fusion [DLIF]; oblique interbody fusion [OLIF]). Cauda equina - A bundle of spinal nerve roots which arise from the termination of the spinal cord proper, it comprises the roots of all the spinal nerves below the first lumbar (L1). Designated Medical Spine Center is a clinic with medical spine specialists whose focus is on the non-surgical, comprehensive management of spine, neck and back problems using a biopsychosocial active re-conditioning model. A Designated Medical Spine Center has shown a commitment to evidence based practice as demonstrated by use of ICSI guidelines and evidence driven protocols. Designated Medical Spine Specialist is a clinician with a specialty in Physical Medicine. Focus On Therapeutic Outcomes (FOTO) - a physical functional status score. This measure is used to assess functional status of patients who received outpatient rehabilitation through the use of self-report health status questionnaires. Measures are taken at intake, during, and at discharge from rehabilitation to assess changes in functional status. Measure results are available in Outcomes Profile Reports, which provide 1) information for clinicians to help direct and improve the care of their patients in real time during treatment, and once treatments are complete, 2) a comparison of the clinician's or facility's outcomes and the National Aggregate in the FOTO Database. Kyphosis - A posterior curvature of the thoracic spine usually the result of a disease (lung disease, Paget's disease) or a congenital problem. Oswestry Disability Index (ODI) - a commonly used outcome-measure questionnaire for low back pain. It is a selfadministered questionnaire divided into ten sections designed to assess limitations of various activities of daily living. Each section is scored on a 0 5 scale, 5 representing the greatest disability. The index is calculated by dividing the summed score by the total possible score, which is then multiplied by 100 and expressed as a percentage. Posterior lumbar spine surgery is performed by approaching the spine through the individual s back by a traditional back midline incision or transforaminally through the opening between two spinal vertebrae (i.e. the foramen) where the nerves leave the spinal canal to enter the body (i.e.,transoframinal lumbar interbody fusion [TLIF]). Scoliosis a congenital lateral curvature of the spine Spinal Stenosis - An abnormal narrowing of the spinal canal that may be either congenital or acquired. Treatment is generally surgical to widen the spinal canal. Laminectomy may be the indicated surgical procedure to reduce pressure on the spinal cord. Spondylolisthesis - Forward movement of one building block of the spine (vertebra) in relation to an adjacent vertebra. Page 3 of 7

4 If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive. The following CPT codes require prior authorization, except for the ICD-10-CM diagnosis codes listed below: Description Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure) Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique) Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (List Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments Posterior non-segmental instrumentation (e.g., Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary - procedure) Posterior segmental instrumentation (e.g., pedicle screw fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure) Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List Unlisted procedure, spine 0195T Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L5-S1 interspace 0196T Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L4-L5 interspace (List 0309T Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 Page 4 of 7

5 interspace (List The following ICD-10-CM do not require prior authorization: Description A17.81 Tuberculoma of brain and spinal cord A18.01 Tuberculosis of spine B90.2 Sequelae of tuberculosis of bones and joints C41.2 Malignant neoplasm of vertebral column C70.1 Malignant neoplasm of spinal meninges C79.31, C79.32 Secondary malignant neoplasm of brain and cerebral meninges Secondary malignant neoplasm of other and unspecified parts of nervous C79.40, C79.49 system C79.51, C79.52 Secondary malignant neoplasm of bone and bone marrow D33.4 Benign neoplasm of spinal cord D32.1 Benign neoplasm of spinal meninges D43.0-D43.2, D43.4 Neoplasm of uncertain behavior of brain and central nervous system D42.0-D42.9 Neoplasm of uncertain behavior of meninges D48.0 Neoplasm of uncertain behavior of bone and articular cartilage G83.4 Cauda equina syndrome G83.9 Paralytic syndrome, unspecified M08.08, M45.0-M45.9, M48.8X1- M48.8X9 Rheumatoid arthritis/ankylosing spondylitis M24.80 Other specific joint derangements of unspecified joint, not elsewhere classified M25.28 Flail joint, other site M53.2X1-M53.2X9 Spinal instabilities Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc M51.9 disorder M51.06 Intervertebral disc disorders with myelopathy, lumbar region M43.27, M43.28 Fusion of spine, lumbosacral & sacrococcygeal regions M53.2X7, M53.2X8 Spinal instabilities, lumbar, sacral & sacrococcygeal regions M53.3 Sacrococcygeal disorders, not elsewhere classified Other specified dorsopathies, lumbar, lumbosacral, sacral & sacrococcygeal M53.86-M53.88 regions M48.50XA-M48.58XS, M80.08XA- M80.08XS, M80.88XA-M80.88XS, M84.58XA-M84.58XS Pathologic fracture of vertebrae M80.00XP, M80.08XP, M80.80XP, M80.88XP, M84.30XP, M84.40XP, M84.48XP, M84.50XP, M84.58XP, M84.60XP, M84.68XP Malunion of fracture M80.00XK, M80.08XK, M80.80XK, M80.88XK, M84.30XK, M84.40XK, M84.48XK, M84.50XK, M84.58XK, M84.60XK, M84.68XK Nonunion of fracture M40.00-M40.05 Postural kyphosis M41.00-M41.35, M96.5 Kyphoscoliosis and scoliosis S12.000A-S12.691B, S12.9XXA- S12.9XXD, S22.000A-S22.089B, S32.000A-S32.059B, S32.10XA- S32.19XB, S32.2XXA-S32.2XXB Fracture of vertebral column without mention of spinal cord injury S32.009A, S32.019A, S32.029A, S32.039A, S32.049A, S32.059A, S34.101A-S34.129S Closed fracture of lumbar spine with spinal cord injury S32.009B, S32.019B, S32.029B, S32.039B, S32.049B, S32.059B, S34.101A-S34.129S Open fracture of lumbar spine with spinal cord injury S31.000A, S33.101A Open dislocation, lumbar vertebra The following ICD-10-CM Diagnoses codes do require prior authorization. This list is not all inclusive. Description M47.20, M47.819, M47.899, M47.9 Spondylosis of unspecified site without mention of myelopathy M51.26, M51.27 Other intervertebral disc displacement, lumbar & lumbosacral regions Page 5 of 7

6 M51.36, M51.37 Other intervertebral disc degeneration, lumbar & lumbosacral regions M96.1 Postlaminectomy syndrome, not elsewhere classified M48.061, M48.062, M48.07, M99.23, M99.33, M99.43, M99.53, M99.63, M99.73 Spinal stenosis of lumbar region M54.5 Low back pain (lumbago) M41.80-M41.9 Other forms of scoliosis M43.8X9 Other specified deforming dorsopathies, site unspecified M40.10-M40.15 Other secondary kyphosis M40.50-M40.57 Lordosis, unspecified M41.40-M41.57 Neuromuscular scoliosis & Other secondary scoliosis M43.00-M43.19 Spondylosis and spondylolisthesis Q76.2 Congenital spondylolisthesis Q Q76.419, Q76.49 Other congenital malformations of spine, not associated with scoliosis S33.0XXA, S33.100A-S33.141S Closed dislocation, lumbar vertebra Diagnosis that are not associated with the scope of this policy & do not require prior authorization, include but is not limited to: Description M47.21-M47.23, M M47.813, M M Cervical spondylosis without myelopathy M M47.029, M Cervical spondylosis with myelopathy M47.13 M47.24, M47.25, M47.814, M47.815, M47.894, M Thoracic spondylosis without myelopathy M47.14, M47.15 Thoracic spondylosis with myelopathy M50.20-M50.23 Other cervical disc displacement M51.24, M51.25 Other intervertebral disc displacement, thoracic & thoracolumbar regions M50.30-M50.33 Other cervical disc degeneration M51.34, M51.35 Other intervertebral disc degeneration, thoracic & thoracolumbar regions M50.00-M50.03 Cervical disc disorder with myelopathy Intervertebral disc disorders with myelopathy, thoracic & thoracolumbar M51.04, M51.05 regions M99.12, S23.100A-S23.171S Subluxation and dislocation of thoracic vertebra S23.101A-S23.101S Dislocation of unspecified thoracic vertebra, initial encounter S14.0XXA-S14.108S, S14.111A- S14.118S, S14.121A-S14.128S, S14.131A-S14.138S, S14.141A- S14.148S, S14.151A-S14.158S Cervical spinal cord injury without evidence of spinal bone injury S24.0XXA-S24.104S, S24.111A- S24.114S, S24.131A-S24.134S, S24.141A-S24.144S, S24.151A- S24.154S Thoracic spinal cord injury without evidence of spinal bone injury CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Products This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at or Approved Medical Director Committee 9/9/08, 9/25/09; Revised 10/15/08, 9/25/09; 5/5/11, 8/18/11, 10/20/11, 12/20/11, 4/18/12, 10/06/17; Annual Review 9/25/09, 9/1/10, 5/2011, 8/2011, 10/2011, 12/2011, 4/2012, 4/2013, 4/2014, 4/2015, 4/2016, 4/2017, 4/2018 References 1. Abbasi H, Abbasi A (October 15, 2015) Oblique Lateral Lumbar Interbody Fusion (OLLIF): Technical Notes and Early Results of a Single Surgeon Comparative Study. Cureus 7(10): e351. DOI /cureus Acosta, F. L., Liu, J., Slimack, N., Moller, D., Fessler, R., & Koski, T. (2011). Changes in coronal and sagittal plane Page 6 of 7

7 alignment following minimally invasive direct lateral interbody fusion for the treatment of degenerative lumbar disease in adults: a radiographic study. Journal of Neurosurgery: Spine, 15(1), doi: / spine10425 Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147: doi: / Chou, R. Subacute and chronic low back pain: Surgical treatment. In: UpToDate, Atlas, SJ (Ed), UpToDate, Waltham, MA. (Accessed on May, 2017.) Eck JC, Sharan A, Ghogawala Z, Resnick DK, Watters WC 3rd, Mummaneni PV, Dailey AT, Choudhri TF, Groff MW, Wang JC, Dhall SS, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 7: lumbar fusion for intractable low-back pain without stenosis or spondylolisthesis.j Neurosurg Spine Jul;21(1):42-7. doi: / SPINE Review. 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Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF. J Spine Surg 2015;1(1):2-18. doi: /j.issn X North American Spine Society (NASS). Clinical Guidelines for diagnosis and treatment of lumbar disc herniation with radiculopathy. (2012). North American Spine Society (NASS). Diagnosis and treatment of adult isthmic spondylolisthesis. (2014). Schroeder GD, Kepler CK, Mba MD, Vaccaro AR. Axial interbody arthrodesis of the L5-S1 segment: A systematic review of the literature. J Neurosurg Spine. 2015;23(3): Sembrano, J. N., Tohmeh, A., Isaacs, R., & SOLAS Degenerative Study Group. (2016). Two-year comparative outcomes of MIS lateral and MIS transforaminal interbody fusion in the treatment of degenerative spondylolisthesis: part I: clinical findings. Spine, 41, S123-S132 Washington State Health Care Authority. Health technology Assessment. Lumbar Fusion for patients with degenerative disc disease- re review. October 16, Accessed October 31, Woods, K. R., Billys, J. B., & Hynes, R. A. (2017). Technical description of oblique lateral interbody fusion at L1 L5 (OLIF25) and at L5 S1 (OLIF51) and evaluation of complication and fusion rates. The Spine Journal, 17(4), Page 7 of 7