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    v1.0.28
    OpenPayerPolicy UpdatesOrthopedics/MusculoskeletalAmbetter Nevada Spinal Fusion Coverage | OpenPayer
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    CurrentAmbetter NevadaPolicy WA.CP.MP.530

    Bone Morphogenic Proteins for Use in Spinal Fusion

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    This policy governs medical necessity and coding considerations for rhBMP-2 and rhBMP-7 used during spinal fusion surgery, including coverage requirements for providers and members/enrollees.

    Policy Summary
    PayerAmbetter Nevada
    PolicyBone Morphogenic Proteins for Use in Spinal Fusion
    Policy CodePolicy WA.CP.MP.530
    Change TypeAnnual review with material coding updates
    Effective DateSeptember 1, 2026
    Last ReviewJun 1, 2026
    Next Review DateN/A
    Key ActionDocument the spinal region, member/enrollee age, procedure type and level, and qualifying revision-fusion criteria when applicable.
    SourceLink
    POLICY UPDATE CHANGES

    The 2026 annual review added CPT codes 22533, 22558, 22612, 22630, and 22633 to the policy.

    A prior revision struck a coverage statement regarding lumbar fusion.

    The policy reference was updated during the June 2026 annual review.

    18+Minimum member/enrollee age for medically necessary rhBMP-2 use
    2Qualifying rhBMP-2 clinical pathways

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    2
    Bone morphogenic proteins addressed
    6CPT codes listed
    Not medically necessaryPolicy stance for rhBMP-7

    Medical Necessity Criteria

    Medically Necessary rhBMP-2

    Bone morphogenic protein-2 (rhBMP-2) is medically necessary when <strong>all</strong> of the following criteria are met:

    ALL of the following

    • Used in the lumbar spine
    • Member/Enrollee is 18 years of age or over

    • ONE of the following

      • Procedure is primary anterior open or laparoscopic fusion at one level between L4 and SI
      • Revision lumbar fusion on a compromised patient for whom autologous bone and bone marrow harvest are not feasible or not expected to result in fusion

    rhBMP-7

    Bone morphogenic protein-7 (rhBMP-7) is not medically necessary.

    rhBMP-7 is not medically necessary for use in spinal fusion

    Bone morphogenic protein-7 (rhBMP-7) is explicitly excluded from the medical-necessity criteria for bone morphogenic proteins used in spinal fusion.

    Bone morphogenic protein-7 (rhBMP-7) is not medically necessary.

    Coding and Qualifying Parameters

    CPT CodesCPT
    20930Allograft, morselized, or placement of osteopromotive material, for spine surgery only.
    22533ARTHRODESIS LATERAL EXTRACAVITARY LUMBAR - Services are administered by Evolent.
    22558ARTHRD ANT INTERBODY MIN DSC LUMBAR - Services are administered by Evolent.
    22612ARTHRODESIS POSTERIOR/PSTLAT TQ 1NTRSPC LUMBAR - Services are administered by Evolent.
    22630ARTHRODESIS POSTERIOR INTERBODY 1 NTRSPC LUMBAR - Services are administered by Evolent.
    22633ARTHRODESIS COMBINED TQ 1NTRSPC LUMBAR - Services are administered by Evolent.
    Minimum Age
    Minimum age18 years of age or over
    Applies toMember/enrollee receiving rhBMP-2 for spinal fusion
    RequirementThe age requirement must be met along with lumbar-spine use and one qualifying procedure pathway
    Lumbar Fusion Level
    Fusion levelOne level between L4 and SI
    Procedure pathwayPrimary anterior open or laparoscopic fusion
    Application

    Documentation and Denial Risks

    Documentation Required

    Document qualifying clinical criteria

    Document that rhBMP-2 is used in the lumbar spine for a member/enrollee who is 18 years of age or over, and identify the qualifying procedure pathway. For primary anterior fusion, specify that it is an open or laparoscopic fusion at one level between L4 and SI; for revision lumbar fusion, document that the patient is compromised and that autologous bone and bone marrow harvest are not feasible or are not expected to result in fusion.

    • Spinal region: lumbar spine
    • Member/enrollee age: 18 years of age or over
    • Procedure type and level: primary anterior open or laparoscopic fusion at one level between L4 and SI, or revision lumbar fusion
    • Revision documentation: compromised patient for whom autologous bone and bone marrow harvest are not feasible or not expected to result in fusion
    Denial Risk

    rhBMP-2 criteria not met

    Policy Background

    Bone morphogenic proteins are used to promote bone formation during spinal fusion. This policy addresses rhBMP-2 when used in specified lumbar fusion circumstances and states that rhBMP-7 is not medically necessary.

    Key Terms

    rhBMP-2
    TermrhBMP-2
    DefinitionRecombinant human bone morphogenic protein-2
    Clinical useUsed in spinal fusion surgery, including specified lumbar fusion circumstances
    rhBMP-7
    TermrhBMP-7
    DefinitionRecombinant human bone morphogenic protein-7
    Policy statusNot medically necessary under this policy
    Policy Summary
    PayerAmbetter Nevada
    PolicyBone Morphogenic Proteins for Use in Spinal Fusion
    Policy CodePolicy WA.CP.MP.530
    Change TypeAnnual review with material coding updates
    Effective DateSeptember 1, 2026
    Last ReviewJun 1, 2026
    Next Review DateN/A
    Key ActionDocument the spinal region, member/enrollee age, procedure type and level, and qualifying revision-fusion criteria when applicable.
    SourceLink
    On This Page
    Medical Necessity CriteriaCoding and Qualifying ParametersDocumentation and Denial RisksPolicy BackgroundKey Terms
    This is one qualifying pathway for medically necessary rhBMP-2 use

    rhBMP-2 may fail medical-necessity criteria if it is not used in the lumbar spine, the member/enrollee is younger than 18, or neither qualifying procedure pathway is met.

    • Use must be in the lumbar spine.
    • The member/enrollee must be 18 years of age or over.
    • A qualifying primary anterior fusion or revision lumbar fusion pathway must be met.
    Denial Risk

    rhBMP-7 use

    rhBMP-7 is considered not medically necessary under this policy and is explicitly excluded from medical necessity.