Indications: Spinal fusion should only be considered as a last step in the treatment of chronic back pain and is not indicated for most persons suffering from back pain. Lumbar spinal fusion surgery may be considered medically necessary and covered for the following indications:
I. Lumbar spinal instability for ANY of the following indications when confirmed by appropriate diagnostic testing (e.g., radiographic imaging, biopsy, bone aspirate, bone scan and gallium scan
II. Spinal stenosis with associated spondylolisthesis (see classifications below), for a single level (e.g., L4-L5), or other documented evidence of instability (e.g., facet joint instability (iatrogenic) related to decompression) when ALL the following criteria are met:
a. Back pain with symptoms of neurogenic claudication or radicular pain
• Radiographic evidence of spondylolisthesis when applicable - Classification of slippage in spondylolisthesis is defined as follows:
Grade I =1% to 25%
Grade II=26% to 50%
Grade III=51% to 75%
Grade IV= 76% to 100%
Grade V = spondyloptosis and occurs when the L5 vertebra completely slides over the top of the sacrum
III. Spondylolysis (i.e., pars interarticular fracture), and isthmic spondylolisthesis, when ANY of the following criteria are met:
Confirmed progressive deformity
• Neurologic compromise
• Symptomatic high grade spondylolisthesis demonstrated on plain x-rays
• Multilevel spondylolysis
• Symptomatic low-grade spondylolisthesis associated with pain and significant functional impairment despite a history of 3 months of conservative therapy
IV. Degenerative disc disease (DDD) in the absence of instability when all of the following criteria have been met as clinically appropriate for the patient’s current episode of care:
• Single level DDD demonstrated on imaging studies (e.g., CT scan, MRI, or discography) as the likely cause of pain. The case specific indications for two level or the rare three or more level planned fusion procedure must be directly addressed in the pre procedure record with clinical correlation to diagnostic testing results (such as disk-space narrowing, end plate changes, annular changes, etc.).
V. Lumbar fusion following prior spinal surgery for the following:
• Recurrent disc herniation despite clinically appropriate post operative nonsurgical medical management (post-operative case specific conservative therapy is prescribed as clinically appropriate in addition to documentation of pain and functional impairment).
• Adjacent segment degeneration despite clinically appropriate post-operative nonsurgical medical management (post-operative case specific conservative therapy is prescribed as clinically appropriate in addition to documentation of pain and functional impairment).
· Associated spondylolisthesis (i.e.,anterolisthesis) after prior spinal surgery
VI. Treatment of pseudoarthrosis (i.e., nonunion of prior fusion) at the same level after 12 months from prior surgery
Lumbar spinal fusion for the following conditions is not considered medically necessary and is noncovered:
• When performed with initial primary laminectomy/discectomy for nerve root decompression or spinal stenosis, without documented spondylolisthesis or documentation of instability (e.g., documented intraoperative iatrogenic instability)
• Lumbar fusion at multi-levels (2 or more) for pure DDD unless case specific indications for two level or the rare three or more level planned fusion procedure is directly addressed in the pre-procedure record
• Medical record documentation maintained by the physician must substantiate the medical need for lumbar spinal fusion surgery and must include the following:
• Office notes/hospital record, including history and physical by the attending/treating physician
• Documentation of the history and duration of unsuccessful conservative therapy (non-surgical medical management) when applicable.
• Interpretation and reports for X-rays, MRI’s, CT’s, etc.
• Medical clearance reports (as applicable)
• Documentation of smoking abstinence (as applicable)
• Complete operative report outlining operative approach used and all the components of the spine surgery
ALL NEED TO HAVE:
• Pain and significant functional impairment despite a history of 3 months of conservative therapy (non-surgical medical management) as clinically appropriate addressing the following:
• Anti-inflammatory medications; Analgesics; Daily exercise; Activity lifestyle modification; Weight reduction as appropriate; Supervised physical therapy (PT) [Activities of daily living (ADLs) diminished despite completing a plan of care
• Patient is a nonsmoker, or has refrained from smoking for at least 6 weeks prior to planned surgery, or has received counseling on the effects of smoking on surgical outcomes and treatment for smoking cessation if accepted.
• If cognitive, behavioral, or addiction issues are identified, the documentation should support assessment and treatment prior to surgical management.