CurrentKaiser PermanentePolicy N/A

Cervical Decompression and/or Fusion (Anterior and Posterior) — Clinical Review Criteria

Clinical review criteria governing medical necessity determinations for cervical fusion and decompression procedures for Kaiser Foundation Health Plan of Washington (non-Medicare and Medicare members). Applies to clinicians requesting authorization for cervical fusion procedures.

Policy Summary

PayerKaiser Permanente

PolicyCervical Decompression and/or Fusion (Anterior and Posterior) — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeRevised criteriaadditions and clarifications

Effective DateAug 1, 202652d

Next Review DateN/A

Key ActionVerify and submit the procedure for Elective Surgical Procedures Level of Care review and provide required supporting documentation (last 6 months of clinical notes and all radiology reports) to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Updated medical necessity criteria for cervical fusion, including removing the requirement that imaging must show cord signal change on MRI for some myelopathy indications.

Quantified conservative treatment physical therapy attendance requirement to >75% of sessions, minimum of 3 visits.

Percutaneous posterior cervical fusion (CAVUX, DTRAX, Corus) declared insufficient evidence / not meeting MTAC criteria and considered not medically necessary.

>=3Required duration of conservative management before fusion for radiculopathy (unless exception)

12Minimum time from prior fusion before pseudoarthrosis revision considered (months)

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.