CurrentCignaPolicy N/A

lumbar_fusion_request_questionnaire

A preauthorization/clinical information questionnaire to be completed and faxed to Cigna to support review of planned lumbar fusion surgery, including required diagnostic reports, conservative treatment history, smoking status, imaging findings, planned procedures/CPT codes, and bone graft/substitute use.

Policy Summary

PayerCigna

Policylumbar_fusion_request_questionnaire

Policy CodePolicy N/A

Change TypeInformational

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed questionnaire and copies of all supporting clinical documentation including MRI and other imaging reports to 866-873-8279 to permit timely review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted in this brief.

ConditionalCoverage for bone graft substitutes

CoveredAllograft morselized bone (CPT 20930)

Not coveredOsteopromotive cell/factor-based grafts

Documentation requiredSingle-level fusion for discogenic low back pain

Document summary and scope

Scope: This is a preauthorization/clinical information questionnaire to be completed and faxed to Cigna to support review of planned lumbar fusion surgery. It requires diagnostic reports (MRI, CT, X-ray, CT myelography), planned procedure details and CPT codes, fusion levels, surgeon name, smoking/tobacco status, conservative treatment history, and documentation of bone graft/substitute use. Status: CURRENT; Subject: Lumbar fusion request questionnaire.

Background: This form is an authorization and clinical information collection tool used by Cigna to support medical necessity review for lumbar fusion procedures. It specifies required documentation, conservative care prerequisites, smoking abstinence requirements, and product-specific coverage notes for bone graft substitutes, including BMP (with single-packet BMP-2 allowed only for medically necessary single-level anterior interbody fusion).

Required documentation to support lumbar fusion requests

Documentation required for lumbar fusion request

To permit a timely review, include ALL of the following documentation and responses:

ALL of the following

Reports of all diagnostic studies performed (MRI, CT, X-ray, CT myelography) supplied with request
Clinical history: onset of symptoms, primary pain location/distribution, symptoms of myelopathy/radiculopathy (weakness, gait imbalance, paresthesias, loss of sensation, bowel or bladder dysfunction)
Functional limitations: ADLs, inability to perform household chores or prolonged standing, interference with essential job functions, disabilities, neurological deficits
Conservative treatment: list treatments provided and duration including exercise, NSAIDs/steroids (unless contraindicated), physical therapy, activity/lifestyle modification
Objective physical exam/findings: sensory changes, motor weakness, reflex changes, sustained clonus, Babinski, toe-to-heel walk, Romberg, loss of sacral sensation or sphincter tone
Diagnostic imaging findings: X-ray findings; MRI or CT scan findings; CT myelography
Patient identifiers and planned procedure details: Customer name/ID/DOB, date of planned surgery, diagnosis, ICD-10 diagnostic codes, procedure description, CPT codes, fusion levels, surgeon name
Smoking/tobacco status: confirmation that patient has not smoked or used tobacco products within past six weeks, or provide quit date for former smoker/former smokeless user6 weeks
Provide quit date for former users

Documentation Required

Submit completed questionnaire and supporting documentation

Fax the completed questionnaire and copies of all supporting clinical documentation to 866-873-8279 to permit timely review. Include MRI and other imaging reports with the submission.

Include MRI and other imaging reports

Documentation Required

Document conservative care and CBT

Provide records demonstrating at least 6 months of structured, physician‑supervised conservative medical management and documentation of participation in at least 3 individual or group cognitive behavioral therapy (CBT) sessions when requesting single‑level fusion for degenerative disc disease without spondylolisthesis.

>= 6 consecutive months of structured conservative medical management
>= 3 individual or group CBT sessions

Documentation Required

Document smoking status

Confirm and document the patient's tobacco use status: patient must have not smoked or used tobacco products within the past 6 weeks prior to planned surgery or provide a quit date for former smokers/former smokeless tobacco users. Exception: if there is progressive neurologic compromise, the 6‑week tobacco abstinence requirement may not apply.

6‑week tobacco‑free period prior to planned surgery or provide quit date
Exception for progressive neurologic compromise

Documentation Required

Identify bone graft substitute product

Specify whether an allograft or bone graft substitute will be used and provide the specific product name (identify BMP, cell‑based, or factor‑based product) as part of the request.

Affected CPT: 20930

Planned surgical techniques / referenced procedure codes

Planned use of specified surgical techniques/devices

The questionnaire asks whether ANY of the following techniques/devices will be utilized:

ONE of

Pre-sacral interbody approach, including axial interbody approach [AxiaLif®] with codes [22586, 0309T, 0195T or 0196T]
Dynamic spine stabilization device systems (e.g., Dynesys®, Stabilimax NZ®)
Total facet arthroplasty, including Total Facet Arthroplasty System TM [0202T]
Isolated facet fusion, with or without instrumentation, including allograft bone graft substitutes used exclusively as stand-alone stabilization devices (e.g., TruFUSE®, NuFix TM) with codes [0221T, 0222T]
Posterior interspinous fixation devices (e.g., Affix TM, Aspen TM, Spinous Process Fixation System)

Referenced CPT / HCPCS codes for specified techniques/devicesmixed

22586	Anterior lumbar interbody fusion (referenced for presacral/axial approaches)
0309T	Axial lumbar interbody fusion (example code referenced)
0195T	Axial lumbar interbody fusion (example code referenced)
0196T	Axial lumbar interbody fusion (example code referenced)
0202T	Total facet arthroplasty
0221T	Isolated facet fusion (device/procedure code)
0222T	Isolated facet fusion (device/procedure code)
20930	Allograft, morselized, or placement of osteopromotive material, for spine surgery only

OpenPayer

lumbar_fusion_request_questionnaire

Document summary and scope

Required documentation to support lumbar fusion requests

Criteria for single-level fusion for discogenic low back pain

Bone graft / bone graft substitute documentation and coverage notes

Planned surgical techniques / referenced procedure codes

Definitions

Document changes and timeline