Total Facet Arthroplasty (Lumbar) — Coverage Criteria
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This policy governs coverage and prior authorization requirements for total facet arthroplasty (posterior vertebral joint replacement) in the lumbar spine for Blue Cross Blue Shield of Massachusetts members across commercial and Medicare products.
No material clinical or coverage changes in this revision.
Coverage Criteria — Lumbar Total Facet Arthroplasty
Investigational / Not Covered
Covered when ALL of the following are met:
Outpatient procedures are explicitly listed as not a covered service for Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, Medicare HMO Blue, and Medicare PPO Blue.
For outpatient settings, total facet arthroplasty is not a covered service for the following products: Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, Medicare HMO Blue SM, and Medicare PPO Blue SM.
Total facet arthroplasty for individuals with lumbar spinal stenosis undergoing spinal decompression is considered investigational for the listed products (Managed Care, PPO, Indemnity, Medicare HMO and Medicare PPO). Claims for investigational procedures may be denied.
Coding and Billing
| 0202T | Posterior vertebral joint(s) arthroplasty (e.g. facet joint[s] replacement) including facetectomy, laminectomy, foraminotomy and vertebral column fixation, with or without injection of bone cement, including fluoroscopy, single level, lumbar spine |
Provider Actions / Authorization / Denial Risk
Inpatient preauthorization required
Precertification/preauthorization is required when the procedure is performed inpatient.
No step therapy specified
This policy does not specify any step therapy requirements.
Inpatient services require precertification
Precertification/preauthorization is required for inpatient performance of the services described in this policy.
Outpatient procedures not covered — potential denial
Outpatient total facet arthroplasty is not a covered service for Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, Medicare HMO Blue, and Medicare PPO Blue; billing for outpatient services may be denied.
Investigational procedure — denial risk
Total facet arthroplasty is considered investigational for the listed products; claims for investigational procedures may be denied.
- Policy states the procedure is considered INVESTIGATIONAL for commercial and Medicare products.
- CPT 0202T is listed as investigational.
Background
Facet arthroplasty implants are designed to replace the posterior elements (facet joints) after neural decompression to provide stabilization of the spine while preserving intervertebral motion. They have been proposed as an alternative to fusion with the intent of reducing adjacent-level degeneration; available evidence consists mainly of preliminary and interim randomized trial reports and case series with outcomes focused on symptoms, function, quality of life, and procedure-related morbidity, and is limited by short follow-up and incomplete reporting.
Definitions
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