CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Axial Lumbosacral Interbody Fusion

Policy governs coverage determination for axial (presacral/transsacral/paracoccygeal) lumbosacral interbody fusion for Commercial Products of Blue Cross Blue Shield Rhode Island, describing clinical overview, evidence assessment, coding and coverage stance. Medicare Advantage plans are excluded and have related policies.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Axial Lumbosacral Interbody Fusion

Policy CodePolicy N/A

Change TypeClarified (last review date updated)

Effective DateFeb 1, 2023

Next Review Date

Key ActionVerify member-specific benefits and coverage under the applicable Benefit Booklet, Evidence of Coverage, Subscriber Agreement, or employer agreement.

SourceLink

POLICY UPDATE CHANGES

Policy updated with last review date 06/04/2025; no clinical policy statement changes indicated in document.

1CPT codes listed as not medically necessary

CommercialPlan scope

Evidence insufficientCoverage rationale

Coverage Summary

Subject: Axial lumbosacral interbody fusion. This policy addresses a minimally invasive anterior (presacral/transsacral/paracoccygeal) approach to interbody fusion targeting the lumbosacral disc spaces.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Short description: Axial lumbosacral interbody fusion is a minimally invasive anterior approach to the L5-S1 (and L4-S1) disc spaces intended to minimize soft-tissue damage while accomplishing interbody fusion under fluoroscopic guidance.

Scope: Policy applies to Commercial Products only (Medicare Advantage plans excluded).

Coverage stance: Not covered (not_covered_cosmetic) for Commercial Products.

Rationale: Evidence insufficient — there is insufficient evidence to determine the effects of the technology on health outcomes, so the procedure is considered not medically necessary for Commercial Products.

Policy metadata

Effective date02/01/2023

Last review06/04/2025

PayerBlue Cross Blue Shield - Rhode Island

Policy titleMedical Coverage Policy Axial Lumbosacral Interbody Fusion

Plan scopeCommercial Products only

Coverage stanceNot medically necessary for Commercial Products (evidence insufficient)

Coverage position for axial lumbosacral interbody fusion:

Commercial Products Coverage Determination: Axial lumbosacral interbody fusion is considered not medically necessary for Commercial Products because evidence is insufficient to determine effects on health outcomes.

Medical-Necessity Criteria

Commercial Products Coverage Determination

Coverage position for axial lumbosacral interbody fusion:

Commercial Products Coverage Determination: Axial lumbosacral interbody fusion is considered not medically necessary for Commercial Products because evidence is insufficient to determine effects on health outcomes.

Medical Criteria

Policy statements regarding medical criteria and prior authorization:

Medical Criteria and Prior Authorization: Medical criteria: Not applicable

Prior Authorization: Prior authorization: Not applicable

Coding

Not Medically Necessary Code(s) for Commercial ProductsCPTNot Covered

22586

Arthrodesis, pre-sacral interbody technique; including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone when performed, L5-S1 interspace

Provider Actions

Documentation Required

Check benefit booklet/contract

Verify member-specific benefits and coverage under the applicable Benefit Booklet, Evidence of Coverage, Subscriber Agreement, or employer agreement because benefits vary between groups and contracts.

Billing Rule

Do not bill member without written consent for non-covered services

Providers may not charge the member for services that are non-covered unless the member was informed and agreed in writing in advance to continue treatment at their own expense.

Background & Evidence

Axial lumbosacral interbody fusion (also called presacral, transsacral, or paracoccygeal interbody fusion) is a minimally invasive technique providing anterior access to the L5-S1 disc space (and L4-S1) for interbody fusion performed under fluoroscopic guidance.

Intended levels: The procedure is intended for the L5-S1 disc space and may be used at L4-S1 in some cases.

Common complications: Complications of the axial approach may include perforation of the bowel, and injury to blood vessels and/or nerves.

FDA and device clearances: The U.S. Food and Drug Administration has cleared multiple anterior spinal intervertebral body fixation device systems through the 510(k) pathway; these systems have specified intended uses and limitations and are not intended for conditions such as severe scoliosis, severe (grade 3–4) spondylolisthesis, tumor, trauma, vertebral compression fractures, or any condition compromising vertebral body mechanical integrity. Device use is limited to anterior supplemental fixation of the lumbar spine at the L5-S1 or L4-S1 disc spaces in conjunction with a legally marketed facet or screw system.

Evidence type	Summary
Systematic review	Found higher fusion rates with transforaminal vs axial interbody fusion; evidence limited by lack of prospective comparative studies.
Comparative/observational studies	Retrospective comparative studies and case series; suggestion of increased complication rates with 2-level axial fusion; overall evidence insufficient for health outcomes.

Axial lumbosacral interbody fusion: Minimally invasive presacral/transsacral/paracoccygeal technique providing anterior access to L4-S1/L5-S1 disc spaces for interbody fusion under fluoroscopic guidance.

Interbody fusion: Surgical procedure that fuses two adjacent vertebral bodies of the spine.

Revision History

2025-06-04clarifiedLatest

Policy updated with last review date 06/04/2025; no clinical policy statement changes indicated in document.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Axial Lumbosacral Interbody Fusion

Policy CodePolicy N/A

Change TypeClarified (last review date updated)

Effective DateFeb 1, 2023

Next Review Date

Key ActionVerify member-specific benefits and coverage under the applicable Benefit Booklet, Evidence of Coverage, Subscriber Agreement, or employer agreement.

SourceLink

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