CurrentCignaPolicy N/A

Cigna Cervical Fusion or Cervical Disc Replacement Precertification Form

Form to be completed and faxed with supporting clinical documentation (including imaging) to request precertification for cervical fusion or cervical disc replacement procedures for Cigna members.

Policy Summary

PayerCigna

PolicyCigna Cervical Fusion or Cervical Disc Replacement Precertification Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective Date

Next Review Date

Key ActionFax the completed questionnaire and required documentation (including MRI and other imaging reports) to 866-873-8279 to request precertification for cervical fusion or disc replacement.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — this administrative form documents required information for precertification but does not change coverage criteria.

866-873-8279Precertification fax number

20930Referenced CPT

6 weeksConservative management threshold

Policy overview

This Cigna administrative precertification form collects standardized clinical and operative details required to request precertification for cervical fusion or cervical disc replacement. It requests patient identifiers, planned procedure descriptions and CPT codes, ICD-10 diagnostic codes, planned fusion or disc replacement levels, surgeon name, pertinent history and physical exam findings, prior surgery and pseudoarthrosis details, tobacco history, and planned use of bone graft products.

Precertification Form — Key Details

PayerCigna

PolicyCigna Cervical Fusion or Cervical Disc Replacement Precertification Form

Policy NumberN/A

StatusCURRENT

Scope summaryForm to be completed and faxed with supporting clinical documentation (including imaging) to request precertification for cervical fusion or cervical disc replacement procedures for Cigna members.

Conservative management duration thresholdat least six weeks

Precertification fax number866-873-8279

What the provider must do

Prior Authorization

Submit completed precertification form and documentation

Fax the completed questionnaire and required documentation, including MRI and other imaging reports, to request precertification for cervical fusion or disc replacement.

Fax number: 866-873-8279
Include MRI and imaging reports

Documentation Required

Provide clinical correlation for levels and indications

Fax clinical documentation that correlates the member's symptoms, physical examination findings, and advanced imaging to support the anatomical levels proposed for surgery. Provide documentation for prior fusion, suspected pseudoarthrosis, iatrogenic instability (including facet removal thresholds), or corpectomy as applicable.

Kyphosis threshold: >11 degrees
Anterolisthesis threshold: >3.5 mm

Documentation Required

Disclose use of bone graft substitutes

If using BMP, cell-based, or factor-based bone graft substitutes, specify the product name on the form and include supporting documentation. Note the CPT descriptor for allograft use and the policy coverage position regarding factor-based grafts.

CPT 20930: allograft, morselized, or placement of osteopromotive material, for spine surgery
Informational: application of osteopromotive cell or factor-based bone graft substitutes is not covered for most spinal fusion procedures (considered experimental/investigational/unproven)

Key thresholds and definitions

Thresholds

Conservative nonoperative management durationat least six weeks

Kyphosis threshold>11 degrees

Anterolisthesis threshold>3.5 mm

Facet removal for iatrogenic instability>=50% bilaterally or >=75% of a single facet

Corpectomy vertebral body removalat least 50% of the vertebral body including the disc above and below

Tobacco abstinence confirmation windowno tobacco use within past six weeks

CPT 20930: allograft, morselized, or placement of osteopromotive material, for spine surgery only. The form requests disclosure of use of BMP, cell-based, or factor-based bone graft substitutes and the specific product name when applicable; the CPT 20930 descriptor is provided for documentation on the form.

Corpectomy documentation requirement: if a corpectomy is planned, the form requires faxing clinical and advanced imaging documentation and notes that a corpectomy code requires documentation that at least 50% of the vertebral body including the disc above and below will be removed.

Policy Summary

PayerCigna

PolicyCigna Cervical Fusion or Cervical Disc Replacement Precertification Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective Date

Next Review Date

Key ActionFax the completed questionnaire and required documentation (including MRI and other imaging reports) to 866-873-8279 to request precertification for cervical fusion or disc replacement.

SourceLink

On This Page

OpenPayer

Cigna Cervical Fusion or Cervical Disc Replacement Precertification Form

Policy overview

Precertification: required clinical and operative details

Requested codes and coding guidance

What the provider must do

Key thresholds and definitions

Document revision history

	Provider to list planned CPT codes (no specific CPTs provided in form)
20930	Allograft, morselized, or placement of osteopromotive material, for spine surgery only