Facet Arthroplasty
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This policy governs coverage determinations for total facet arthroplasty (implantation of posterior spinal prosthesis) as an alternative to posterior spinal fusion for lumbar spinal stenosis, spondylolisthesis, and facet arthrosis for Blue Cross Blue Shield - Rhode Island members.
No material clinical or coverage changes in this revision.
Coverage Criteria
Coverage stance by product
Policy coverage determinations differ by product type:
For Medicare Advantage and Commercial products, CPT code 0202T (Posterior vertebral joint(s) arthroplasty, single level, lumbar spine) is listed as not covered for Medicare Advantage Plans and not medically necessary for Commercial Products.
For Commercial Products, total facet arthroplasty (CPT 0202T) is considered not medically necessary. The policy states that evidence is insufficient to determine the effects of the technology on health outcomes for individuals with lumbar spinal stenosis undergoing spinal decompression, and the listed CPT code is identified as not medically necessary for Commercial members.
Coding and Billing
| 0202T | Posterior vertebral joint(s) arthroplasty (eg, facet joint[s] replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine |
Provider Actions and Billing Guidance
Check plan-specific prior authorization rules
Prior authorization is not applicable for total facet arthroplasty under this policy; however, benefits and any plan-specific authorization requirements may vary by contract and should be checked with the member's plan.
- Policy statement: "PRIOR AUTHORIZATION Not applicable."
- Verify plan-specific rules because "Benefits may vary between groups/contracts."
No step therapy specified in policy
This policy does not specify any step therapy or prerequisite medical criteria for total facet arthroplasty.
- Medical criteria: "Not applicable"
- Step therapy: "No medical criteria or step therapy specified in this policy."
Verify member benefits and eligibility
Confirm member benefits and eligibility prior to performing or billing for the procedure, as coverage and benefit provisions vary by group/contract and the member's Benefit Booklet or Evidence of Coverage governs.
- Refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable benefits.
- For member-specific benefits, contact the provider call center.
High risk of coverage denial—not covered / not medically necessary
Claims for total facet arthroplasty may be denied: the procedure is not covered for Medicare Advantage and is considered not medically necessary for Commercial products.
- Medicare Advantage: "Total facet arthroplasty ... is considered not covered."
- Commercial Products: "... is considered not medically necessary."
- CPT 0202T is listed as not covered/not medically necessary.
Background
Facet arthroplasty implants are designed to replace excised posterior elements and facet joints as an adjunct to neural decompression. Their intended function is to stabilize the spine while preserving motion at the treated segment, offering an alternative to posterior spinal fusion that may reduce adjacent-level degeneration by maintaining segmental motion.
Definitions
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