Medical Policy Original Effective Date: Revised Date: Page 1 of 11

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1 Page 1 of 11 Content Disclaimer Description Coverage Determination Clinical Indications Lumbar Spine Surgery Lumbar Spine Surgery Description Indication Coding Lumbar Spinal Fusion (single level)surgery Lumbar Spinal Fusion (multiple levels) Surgery Lumbar Decompression Procedures Lumbar Discectomy/Microdiscectomy procedure Cervical Spine Surgery Cervical Description Indications Coding Anterior Cervical Decompression with Fusion (ACDF) Single level Anterior Cervical Decompression with Fusion (ACDF) Multiple level: Cervical Posterior Decompression with Fusion Single Leve Cervical Posterior Decompression with Fusion- Multiple Levels: Cervical Artificial Disc Single Level: Cervical Artificial Disc Two Levels: Cervical Posterior Decompression (without fusion): Cervical Anterior Decompression (without fusion): Refer to the member s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans or the plan may have broader or more limited benefits than those listed in this. This addresses clinical indications for cervical and lumbar spinal surgeries. Prior Authorization is required, Log on to the NIA Magellan website: to submit a Request an Exam.

2 Page 2 of 11 Presbyterian now uses NIA Magellan Lumbar Spinal Surgery, 2018 Magellan Clinical Guidelines. Lumbar Spine Surgery Lumbar Spine Surgery Lumbar Spinal Fusion Surgery Lumbar Decompression Procedures Lumbar Microdiscectomy Only Procedures Description Artificial disc replacement is an alternative to spinal fusion for the treatment of symptomatic disc disease. These devices are designed to maintain the function of the natural spine by preserving motion, and to potentially limit the incidence of adjacent segment degeneration. Presbyterian Health Plan covers cervical artificial disc replacement, but does not cover lumbar artificial disc replacement This guideline outlines the key surgical treatments and indications for common lumbar spinal disorders and is a consensus document based upon the best available evidence. Spine surgery is a complex area of medicine and this document breaks out the treatment modalities for lumbar spine disorders into surgical categories: lumbar discectomy/microdiscectomy, lumbar decompression, and lumbar fusion surgery. Indication INDICATIONS FOR LUMBAR SURGERY: (This section of the clinical guidelines can be found on the Magellan Clinical guideline, which thoroughly provides the clinical criteria for each of the lumbar and presacral spine surgery categories.) I. Indications for Lumbar Discectomy/Microdiscectomy: Surgical indications for intervertebral disc herniation: II. III. IV. Indications for Lumbar Decompression: Laminectomy, Laminotomy, Facetectomy, and Foraminotomy. These procedures allow decompression by partial or total removal of various parts of vertebral bone and ligaments. Surgical Indications for spinal canal decompression due to lumbar spinal stenosis: Indications for Lumbar Spine Fusion: CONTRAINDICATIONS FOR SPINE SURGERY (Note: Cases will not be approved if the below contraindications exist):

3 Page 3 of Medical contraindications 2. Psychosocial risk factors. 3. Active Tobacco or Nicotine 4. Morbid Obesity V. Other ADDITIONAL INFORMATION Coding The coding listed in this medical policy is for reference only. Covered and non-covered codes are within this list Lumbar Spinal Fusion (single level)surgery Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace; lumbar discectomy to prepare interspace; (other than for decompression); lumbar lumbar (with lateral transverse technique, when performed) Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace, single interspace; lumbar Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace, single interspace and segment; lumbar For CPT codes listed above include also Decompression (see below for codes) Lumbar Spinal Fusion (multiple levels) Surgery Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace; lumbar Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace; thoracic or lumbar, each additional vertebral segment discectomy to prepare interspace; lumbar discectomy to prepare interspace; each additional interspace. (List separately in addition to code for primary procedure) Code

4 Page 4 of 11 Lumbar Spinal Fusion (multiple levels) Surgery first ( ) lumbar each additional vertebral segment. (List separately in addition to code for primary procedure) Code first (22612, 22630,22633) Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace, single interspace; lumbar Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace, single interspace; each additional interspace. (List separately in addition to code for primary procedure). Code first (22612, 22630, 22633) Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace, single interspace and segment; lumbar Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace, single interspace and segment; each additional interspace and segment. (List separately in addition to code for primary procedure). Code first (22633) For CPT codes listed above include also Decompression (see below for codes) Lumbar Decompression Procedures Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis. Laminectomy with removal of abnormal facets and/or pars interarticularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, more than 2 vertebral segments; lumbar

5 Page 5 of Lumbar Decompression Procedures intervertebral disc; 1 interspace, lumbar intervertebral disc; each additional interspace, cervical or lumbar. (List separately in addition to code for primary procedure). Code first ( ) Laminotomy,(hemilaminectomy) with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar Laminotomy, (hemilaminectomy) with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace. (List separately in addition to code for primary procedure). First code (63042) Laminectomy, facetectomy and foraminotomy, (unilateral or bilateral with decompression of spinal cord, cauda equine and/or nerve root[s]. [eg, spinal or lateral recess stenosis]), (single vertebral segment; lumbar Laminectomy, facetectomy and foraminotomy, (unilateral or bilateral with decompression of spinal cord, cauda equine and/or nerve root[s]. [eg, spinal or lateral recess stenosis]), (single vertebral segment; each additional segment, cervical, thoracic, or lumbar. (List separately in addition to code for primary procedure). Code first ( ). Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s), single segment; lumbar. Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s), single segment; each additional segment, thoracic or lumbar. (List separately in addition to code for primary procedure). Code first ( ) s Lumbar Discectomy/Microdiscectomy procedure intervertebral disc; 1 interspace, lumbar intervertebral disc; each additional interspace, cervical or

6 Page 6 of 11 s s Lumbar Discectomy/Microdiscectomy procedure lumbar. (List separately in addition to code for primary procedure).code first ( ) Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar. Lumbar Artificial Disc Replacement (not payable) Total disc arthroplasty, anterior approach, including discectomy to prepare interspace, single interspace, lumbar Revision including replacement of total disc arthroplasty, anterior approach, single interspace; lumbar Removal of total disc arthroplasty, anterior approach, single interspace; lumbar Cervical Spine Surgery Cervical Description 1. Anterior Cervical Decompression with Fusion - Single Level (ACDF) 2. Anterior Cervical Decompression with Fusion - Multiple Level (ACDF) 3. Cervical Posterior Decompression with Fusion - Multiple Levels 4. Cervical Posterior Decompression with Fusion - Single Level 5. Cervical Artificial Disc - Single Level 6. Cervical Artificial Disc - Two Levels 7. Cervical Posterior Decompression (without fusion) 8. Cervical Anterior Decompression (without fusion) Artificial disc replacement is an alternative to spinal fusion for the treatment of symptomatic disc disease. These devices are designed to maintain the function of the natural spine by preserving motion, and to potentially limit the incidence of adjacent segment degeneration. Artificial disc replacements are available for the lumbar and cervical spine. Presbyterian Health Plan covers cervical artificial disc replacement, but does not cover lumbar artificial disc replacement This guideline outlines the key surgical treatments and indications for common cervical spinal disorders and is a consensus document based upon the best available evidence. Spine surgery is a complex area of

7 Page 7 of 11 medicine, and this document breaks out the clinical indications by surgical type. Operative treatment is indicated only when the natural history of an operatively treatable problem is better than the natural history of the problem without operative treatment. Choice of surgical approach is based on anatomy, the patient's pathology, and the surgeon's experience and preference. All operative interventions must be based on a positive correlation with clinical findings, the natural history of the disease, the clinical course, and diagnostic tests or imaging results. Indications Coding s INDICATIONS FOR CERVICAL SURGERY: This section of the clinical guidelines can be found on the Magellan Clinical guideline, which thoroughly provides the clinical criteria for the following: I. Anterior Cervical Decompression with Fusion (ACDF) - Single Level: II. III. IV. Anterior Cervical Decompression with Fusion (ACDF) - Multiple Level: Cervical Posterior Decompression with Fusion - Single Level: Cervical Posterior Decompression with Fusion - Multiple Levels: V. Cervical Fusion for Treatment of Axial Neck Pain: VI. VII. VIII. IX. Cervical Posterior Decompression: Cervical Artificial Disc Replacement (Single or Two Level) Cervical Fusion without Decompression Cervical Anterior Decompression (without fusion) X. ADDITIONAL INFORMATION The coding listed in this medical policy is for reference only. Covered and non-covered codes are within this list Anterior Cervical Decompression with Fusion (ACDF) Single level Arthrodesis, anterior transoral or extraoral technique, clivus-c1- C2, with or without excision of odontoid process Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 discectomy to prepare interspace; cervical below C2

8 Page 8 of 11 s Anterior Cervical Decompression with Fusion (ACDF) Multiple level: Arthrodesis, anterior transoral or extraoral technique, clivus-c1- C2, with or without excision of odontoid process Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace. (List separately in addition to code for primary procedure). Code first (22551) discectomy to prepare interspace; cervical below C2 discectomy to prepare interspace; each additional interspace. (List separately in addition to code for primary procedure). Code first (22554). s Cervical Posterior Decompression with Fusion Single Level Arthrodesis, posterior technique, craniocervical Arthrodesis, posterior technique, atlas-axis s cervical below C2 segment Cervical Posterior Decompression with Fusion- Multiple Levels: Arthrodesis, posterior technique, craniocervical Arthrodesis, posterior technique, atlas-axis cervical below C2 segment each additional vertebral segment. (List separately in addition to code for primary procedure). Code first (22600)

9 Page 9 of T 0095T **0375T Cervical Artificial Disc Single Level: Total disc arthroplasty, anterior approach, including discectomy with end plate preparation; single interspace, cervical Revision including replacement of total disc arthroplasty, anterior approach, single interspace; cervical Removal of total disc arthroplasty, anterior approach, single interspace; cervical Cervical Artificial Disc Two Levels: Total disc arthroplasty, anterior approach, including discectomy with end plate preparation; second level, cervical Revision including replacement of total disc arthroplasty, anterior approach, each additional interspace, cervical Removal of total disc arthroplasty, anterior approach, each additional interspace, cervical **0375T is not a covered service and is not reimbursable. Total disc arthroplasty, anterior approach, including discectomy with end plate preparation, cervical, three or more levels Cervical Posterior Decompression (without fusion): Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, 1 or 2 vertebral segments; cervical Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, more than 2 vertebral segments; cervical intervertebral disc; 1 interspace, cervical intervertebral disc, reexploration, single interspace; cervical Laminectomy, facetectomy and foraminotomy, (unilateral or bilateral with decompression of spinal cord, cauda equine and/or nerve root[s]. [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements

10 Page 10 of References Cervical Posterior Decompression (without fusion): intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure). Code first ( ) intervertebral disc, reexploration, single interspace; each additional cervical interspace. (List separately in addition to code for primary procedure). Code first (63040) Laminectomy, facetectomy and foraminotomy, (unilateral or bilateral with decompression of spinal cord, cauda equine and/or nerve root[s]. [eg, spinal or lateral recess stenosis]), (single vertebral segment; each additional segment, cervical, thoracic, or lumbar (Code first ( ). (List separately in addition to code for primary procedure) Cervical Anterior Decompression (without fusion): Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace. (List separately in addition to code for primary procedure) Code first (63075). 1. NIA Magellan, Lumbar Spinal Fusion Surgery, Lumbar Decompression Procedures, Lumbar Microdisectomy Only Procedure, Guideline Number: NIA_CG_304, last revised date: March Accessed 07/31/ NIA Magellan, CERVICAL SPINE SURGERY, Guideline Number: NIA_CG_307, last revised date: January Accessed 07/31/ Magellan Clinical Guidelines for Medical Necessity Review, Version:4, Effective January Accessed 08/03/2018. Approval Signatures: Clinical Quality Committee: Thomas Rothfeld MD Medical Director: Norman White MD

11 Page 11 of 11 Date Approved: January 24, 2018 Publication History: Annual Review. Change to NIA Magellan Lumbar Spine Surgery criteria available on the RAD MD website Annual Review. See NIA Magellan criteria on RAD MD website The following Medical Policies were merged into this policy: Artificial Disc Replacement MPM 1.3 Lumbar Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy, MPM 12.0 Lumbar Fusion (Arthrodesis), MPM 12.1 This is intended to represent clinical guidelines describing medical appropriateness and is developed to assist Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) Health Services staff and Presbyterian medical directors in determination of coverage. The is not a treatment guide and should not be used as such. For those instances where a member does not meet the criteria described in these guidelines, additional information supporting medical necessity is welcome and may be utilized by the medical director in reviewing the case. Please note that all Presbyterian medical policies are available on the Internet at: