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.

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

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.