ModifiedKaiser PermanentePolicy N/A

Clinical Review Criteria — Lumbar Decompression & Fusion Procedures

Clinical review criteria governing medical necessity and documentation requirements for lumbar laminectomy, lumbar fusion, spinal decompression devices, and minimally invasive lumbar decompression for Kaiser Permanente Washington members and providers.

Policy Summary

PayerKaiser Permanente

PolicyLumbar Decompression & Fusion Procedures — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeConsolidation + coding updates (added 62287removed 22867-22870)

Effective DateEffective 01/01/2026 for some changes

Next Review DateN/A

Key ActionSubmit elective lumbar laminectomy and fusion requests for Elective Surgical Procedures level-of-care review with supporting documentation including imaging and conservative therapy records.

SourceLink

POLICY UPDATE CHANGES

Consolidated Lumbar Laminectomy, Lumbar Fusion, Spinal Decompression Device (Xstop), Minimally Invasive Lumbar Decompression (MILD/PILD) criteria into one policy.

Removed spinal decompression codes 22867-22870 from criteria.

Added CPT code 62287 to Non‑Medicare not medically necessary list and clarified its use.

3 monthsConservative before fusion

6 weeksConservative before laminectomy

12 monthsImaging recency

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Planned effective date

C1821, 22867-70Not medically necessary codes

1Policy committee approvals

Coverage and Medical Necessity Criteria

Laminectomy (lumbar spinal stenosis)

Laminectomy for lumbar spinal stenosis is covered when ALL of the following are met:

Clinical presentation: Neurogenic claudication or radicular pain with VAS >= 4 and significant functional impairment

Imaging: Documentation of central, lateral recess, or foraminal stenosis on MRI or CT myelography performed within the past 12 months that correlates with clinical findings12 months

Conservative care: Failure to respond to at least 6 weeks of continuous conservative management within the past 12 months6 weeks

Laminectomy/Laminotomy for disc herniation

Laminectomy/laminotomy for lumbar disc herniation is covered when ALL of the following are met:

Clinical signs: Nerve root tension sign and radicular pain with significant functional impairment and/or physical exam findings consistent with radiculopathy (dermatomal sensory loss, abnormal reflex changes, or motor strength deficit)

Imaging: Documentation of a disc herniation causing nerve root compression or thecal sac impingement on MRI or other advanced imaging performed within the past 6 months that correlates with clinical findings6 months

Other sources ruled out: All other reasonable sources of pain have been ruled out

Laminotomy vs laminectomy justification: If laminectomy is requested, documentation must indicate laminotomy is relatively contraindicated due to increased risk of iatrogenic neurologic deficit

Lumbar synovial cyst removal

Synovial cyst removal is covered when ALL of the following are met:

Symptoms: Radicular pain (with or without neurologic deficits) or neurogenic claudication that has not responded to at least 6 weeks of continuous conservative management within the past 12 months6 weeks

Imaging: Documentation of a synovial cyst on CT or MRI performed within the past 6 months that correlates with symptoms and examination findings6 months

Lumbar fusion indications

Lumbar spinal fusion may be indicated for ONE or more of the following groups of indications (each group has internal ALL/OR logic as noted):

Acute spinal fracture: Spinal fracture repair when indicated by spinal instability due to trauma or neural compression from trauma

Spondylolisthesis with stenosis: Imaging demonstrating spondylolisthesis (>= 4 mm forward shift on standing flexion/extension X-rays OR qualifying Myerding grade) AND clinically important spinal stenosis with significant functional impairment AND failure of at least 3 months of conservative therapy3 months

Revision fusion / adjacent segment disease: Radiographic evidence of adjacent segment disease with persistent disabling symptoms and failure of 3 months of conservative therapy3 months

Covered lumbar procedures (general rule)

Covered when the applicable policy statements' medical necessity criteria are met

General rule: Procedure codes for lumbar decompression, microdiscectomy, fusion, instrumentation, and grafting are considered medically necessary only when the specific policy criteria referenced elsewhere in this policy are satisfied and documented.

Documentation must demonstrate that the applicable criteria are met before coverage is approved.

Spinal Decompression Device — Not Medically Necessary

Not covered / Not medically necessary

Interspinous devices: Insertion or implantation of interspinous process distraction/stabilization devices (e.g., C1821, CPT 22867–22870) is considered Not Medically Necessary.

Billing these codes may result in denial; see coding section for listed codes.

Coverage stance — Medicare vs Non‑Medicare and device coding

Policy coverage stance as stated in this fragment:

Medicare MILD/PILD: For Medicare members, Minimally Invasive Lumbar Decompression (MILD/PILD) is considered medically necessary when criteria in the applicable policy statements listed above are met.

Refer to Medicare-specific criteria in the policy.

Non-Medicare MILD/PILD and percutaneous decompression codes: For Non‑Medicare members, percutaneous/minimally invasive decompression codes (for example CPT 62287 and 0275T) are considered Not Medically Necessary.

Providers should verify preauthorization requirements by plan via the Pre-authorization Code Check.

Interspinous process devices: Interspinous process distraction devices (HCPCS/CPT C1821 and CPT codes 22867–22870) are considered Not Medically Necessary for members covered under this policy.

These device positions were consolidated and updated in policy revisions.

Procedures intended to treat axial low back pain without a neural component are considered not medically necessary. Examples include isolated disc bulge or herniation without nerve compression and degenerative findings such as annular tear or disc degeneration when symptoms are limited to low back pain. As stated in the policy, indications other than those specifically addressed (for example, asymptomatic spinal stenosis or symptoms limited to low back pain) are excluded and may be denied. The requirement for a period of conservative management may be waived only when there is evidence of progressive nerve or spinal cord compression with a significant neurologic deficit or cauda equina syndrome.

Spinal decompression implants such as Coflex, Vertiflex, and Superion are treated as spinal distraction/interspinous process devices and are not covered per the referenced MCG guideline (A-0494). The policy explicitly lists interspinous process distraction/stabilization devices as Not Medically Necessary, consistent with the MCG-based coverage determination.

Percutaneous image-guided lumbar decompression procedures (commonly called PILD/MILD) have limited support in the evidence base. The policy states these services are non-covered when furnished outside a CMS-approved CED study due to insufficient evidence. For Non‑Medicare members, select percutaneous/minimally invasive decompression codes (for example, 62287 and 0275T) are listed as Not Medically Necessary and may be denied unless coverage criteria specific to Medicare (such as within a CED or Medicare-specific criteria) apply.

Insertion or implantation of interspinous process distraction/stabilization devices is explicitly listed as Not Medically Necessary. The policy names relevant codes (for example, C1821, 22867–22870) and indicates these device procedures are considered non-covered.

Use of the interspinous device codes and certain percutaneous decompression codes is explicitly considered Not Medically Necessary for Non‑Medicare members. The policy highlights device insertion codes (e.g., C1821, 22867–22870) and minimally invasive decompression codes (e.g., 62287, 0275T) as positions that may be denied when billed for Non‑Medicare plans.

Procedures performed for indications not listed in the policy, or those addressing purely axial low back pain without evidence of neural compression, are considered Not Medically Necessary. The policy lists these scenarios among exclusions and notes they may be denied if submitted without supporting indications that meet the documented criteria.

To restate the policy position: Insertion of interspinous process distraction/stabilization devices is Not Medically Necessary. Providers should expect these services and the associated device codes to be non‑covered.

The policy specifically calls out the following codes as Not Medically Necessary for Non‑Medicare coverage positions (when listed): C1821, 22867, 22868, 22869, 22870, and the percutaneous decompression codes 62287 and 0275T. These codes are highlighted for preauthorization verification and may be denied when billed for Non‑Medicare members.

Procedure and Coding Tables

Lumbar Decompression SurgeriesCPTCovered

63011	Laminectomy with exploration andlor decompression of spinal cord andlor cauda equina, without facetectomy, foraminotomy or discectomy; 1 or 2 vertebral segments; sacral.
63052	Laminectomy, facetectomy, or foraminotomy during posterior interbody arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure).
63053	Laminectomy, facetectomy, or foraminotomy during posterior interbody arthrodesis, lumbar; each additional vertebral segment (List separately in addition to code for primary procedure).

Lumbar Microdiscectomy / Decompression CPTsCPTCovered

63030	Laminotomy (hemilaminectomy) with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; lumbar.
63035	Laminotomy with decompression; each additional interspace.
63042	Re-exploration laminotomy single interspace; lumbar.
63056	Transpedicular approach with decompression, single segment; lumbar (including transfacet or lateral extraforaminal approach).
63057	Each additional segment transpedicular approach (list separately).

Lumbar Spine Non-Medicare Arthrodesis / InstrumentationCPTCovered

22533	Arthrodesis, lateral extracavitary technique; lumbar.
22612	Arthrodesis, posterior or posterolateral technique, single level; lumbar.
22630	Arthrodesis, posterior interbody technique, single interspace; lumbar.
22633	Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique; single interspace; lumbar.
22800	Arthrodesis, posterior for spinal deformity, up to 6 vertebral segments.
22853	Insertion of interbody biomechanical device(s) with integral anterior instrumentation to intervertebral disc space (list separately).
22854	Insertion of intervertebral biomechanical device(s) to vertebral corpectomy defect; in conjunction with interbody arthrodesis.

Graft and Percutaneous CodesmixedCovered

S2348	Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency.
20930	Grafting or placement of osteopromotive material for spine surgery only (list separately).
20936	Autograft for spine surgery only (includes harvesting the graft); local.
20937	Autograft for spine surgery only; morselized (through separate incision).
20938	Autograft for spine surgery only; structural, bicortical or tricortical.

Spinal Decompression Device (Interspinous) CodesCPT/HCPCSNot Covered

C1821	Interspinous process distraction device (implantable).
22867	Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, with open decompression, lumbar; single level.
22868	Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, with open decompression, lumbar; second level.
22869	Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, lumbar; single level.
22870	Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, lumbar; second level.

Spinal decompression device codesHCPCS|CPTNot Covered

C1821	Interspinous process distraction device_(implantable)
22867	Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level
22868	Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure)
22869	Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level
22870	Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure)

Minimally invasive lumbar decompression codesCPTNot Covered

62287	Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle-based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar
0275T	Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg fluoroscopic/CT) single or multiple levels — unilateral or bilateral; lumbar

Spondylolisthesis radiographic threshold — numeric thresholds and Myerding grades (table referenced)

Radiographic threshold>= 4 mm forward shift on standing flexion/extension plain X‑rays

Alternate threshold (Myerding)Myerding grade >= I (see Myerding grading table for I–V definitions)

Imaging view requiredStanding flexion/extension sagittal plane radiographs (lateral view) to measure anterior vertebral slip

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Expected for Listed Lumbar Procedure Codes

Prior authorization is expected for the listed lumbar procedure codes. Providers should request prior authorization for decompression, microdiscectomy, fusion, instrumentation, grafting, and related lumbar procedures prior to elective scheduling.

Applicable lumbar procedure codes (decompression, microdiscectomy, fusion, instrumentation, interbody device insertion, grafting) are included in the code lists in this policy. See Applicable Codes sections for full lists.
To verify authorization requirements for a specific code by plan type, use the Pre-authorization Code Check.

Prior Authorization

Preauthorization Requirement — Verify Per Plan

Preauthorization (prior authorization) is a plan-level requirement for many of the lumbar procedures in this policy. Verify authorization requirements for the member's specific plan and code before scheduling; some codes may require Level of Care review for elective procedures.

Examples of codes that frequently require verification: 62287, 0275T, interspinous device codes (C1821, 22867–22870).

Background and Evidence Summary

Background: Chronic lower back pain is a common clinical problem with heterogeneous causes including degenerative disc disease, disc herniation, facet arthropathy, and other structural lesions. Many patients improve with conservative care (medications, injections, supervised physical therapy); surgical interventions are reserved for cases with structural pathology correlating with neurologic compromise or for patients who fail appropriate conservative management. The policy distinguishes conditions warranting surgery from those (for example, isolated axial low back pain without neural compression) that are excluded from coverage.

Completion of optimal package of care — combined physical and psychological treatment program and failure of conservative therapies

Definition of optimal package of careIncludes a combined physical and psychological treatment program as part of completed optimal care before considering fusion

Failure of conservative therapiesPersistent severe non‑specific low back pain despite completion of conservative care (e.g., medications, PT, injections) before referral for fusion

Guideline basisNICE and APS guidance recommend considering fusion only after optimal package of care has been completed

Policy Summary

PayerKaiser Permanente

PolicyLumbar Decompression & Fusion Procedures — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeConsolidation + coding updates (added 62287removed 22867-22870)

Effective DateEffective 01/01/2026 for some changes

Next Review DateN/A

SourceLink

On This Page

Conservative care: Failure of at least 6 weeks of continuous conservative management within the past 12 months6 weeks

Documented pseudoarthrosis: CT imaging >= 12 months post-op showing lucency around hardware, hardware fracture, or absence of bridging arthrodesis AND prior fusion >= 12 months earlier with persistent daily axial back pain12 months

Recurrent disc herniation after prior microdiscectomy: Previous disc surgery > 6 months ago AND recurrent neurogenic claudication or radicular pain unresponsive to 3 months of conservative therapy AND imaging documenting neural compression at the same level3 months

Use the Pre-authorization Code Check to confirm per-plan requirements and any Medicare vs Non‑Medicare differences.

Denial Risk

Not Medically Necessary Triggers and Denial Risks

Procedures and indications that lack an appropriate neural component or do not meet the documented criteria are considered not medically necessary and are at high risk for denial.

Not medically necessary triggers include: axial low back pain without a neural component; disc bulge or herniation without nerve compression; degenerative disc disease/annular tears without nerve compression; asymptomatic spinal stenosis or stenosis with symptoms limited to axial low back pain.
Interspinous process distraction/stabilization devices (C1821, 22867–22870) are considered not medically necessary.
Percutaneous/minimally invasive decompression codes (62287, 0275T) are considered not medically necessary for Non‑Medicare members per this policy — verify membership type and plan-specific coverage.

Denial Risk

Percutaneous/Minimally Invasive Decompression — Denial Risk

Percutaneous and minimally invasive decompression procedures are subject to denial risk for Non‑Medicare members and may require preauthorization and detailed documentation when permitted.

Codes called out for denial risk: 62287 (percutaneous decompression of nucleus pulposus) and 0275T (percutaneous/interlaminar minimally invasive decompression) — Non‑Medicare members: considered not medically necessary per policy.
Confirm Medicare-specific NCD/NPR guidance separately; for Medicare members some percutaneous image‑guided lumbar decompression indications may follow different rules.

Documentation Required

Required Documentation for Prior Authorization

Submit comprehensive documentation with all prior authorization requests to support medical necessity for lumbar procedures.

Clinical notes including the specific procedure(s) requested, related procedure and diagnosis codes, and identification of disc levels planned for surgery.
Complete History & Physical (H&P) and documentation of activity of daily living (ADL) limitations.
Duration, character, location, and radiation of pain; focused physical examination findings.
Pertinent imaging reports (including flexion‑extension X‑rays if instability is suspected) and radiology reads by a radiologist when applicable.
Evidence of specific prior conservative treatments attempted and their outcomes (see conservative therapy documentation requirements).

Documentation Required

Documentation Expectations Referenced

Documentation expectations referenced in the policy must be included and mapped to the requested procedure code(s) to demonstrate medical necessity.

Map clinical and imaging findings to the indications listed for each code (e.g., neural compression, segmental instability, radiculopathy with objective deficits).
Include spondylolisthesis grading (Myerding scale) when applicable, smoking status/cessation counseling, BMI if referenced by criteria, and quantification of conservative care (see conservative therapy documentation).
If conservative therapy was not appropriate or waived (e.g., progressive neurologic deficit, cauda equina), explicitly document the rationale.

Prior Authorization

Conservative Therapy Requirement

Conservative (non‑operative) therapy is generally required prior to elective lumbar surgery except when waived for urgent neurologic compromise. Typical prerequisites and expectations are defined below.

Usual prerequisite: a trial of at least 3 months of non‑operative treatment including medication (NSAIDs, acetaminophen, other indicated agents) and physical therapy.
Conservative therapy should include supervised physical therapy with attendance ≥75% of sessions and a minimum of 3 visits; at least half of PT should be in‑person (not virtual).
Epidural steroid injections may be part of the conservative package when appropriate.
If conservative therapy is not appropriate for clinical reasons (progressive neurologic deficit or cauda equina syndrome), the medical record must clearly document why it was waived.

Prior Authorization

Conservative Care Before Fusion

For spinal fusion and complex lumbar procedures, completion of an optimal package of non‑surgical care is expected before considering surgery for non‑radicular low back pain.

Optimal non‑surgical care may include combined physical and psychological treatment programs and other intensive rehabilitation measures prior to fusion for non‑specific low back pain.
Discuss risks and benefits of fusion versus intensive nonoperative rehabilitation; ensure documentation that conservative care was completed and outcomes recorded.

Documentation Required

Conservative Therapy Documentation — Quantify Measures

When documenting conservative therapy, quantify the therapies and outcomes in the submission to support medical necessity.

Specify number of PT visits, attendance percentage, type (in‑person vs virtual), and the nature of exercises and activity restrictions.
Document medication trials (drug names, doses, durations), timing and results of epidural injections, and patient response or function change.
Include dates and duration of conservative care and link these to the timeline of symptoms and imaging findings.

Neurogenic claudication — definition and clinical features

Core definitionBilateral or unilateral leg pain on standing and walking that is temporarily relieved by forward flexion or sitting/lying down

Typical provocationSymptoms occur with upright posture and ambulation

Typical relief maneuversForward flexion (bending forward) or sitting/lying down relieves symptoms

Radicular pain / suspected radiculopathy — definition and supporting exam findings

Core definitionLeg pain >= back pain in a nerve‑root distribution (e.g., L5, S1) plus one or more supporting findings

Supporting exam findingsPositive supine straight‑leg‑raise reproducing radicular pain (>30 degrees), motor weakness or sensory loss in a specific radicular distribution

Electrodiagnostic supportEMG/NCS confirming acute radiculopathy consistent with the patient's symptoms can support diagnosis

Conservative treatment (pre-2026 and effective Jan 1, 2026) — components of prior conservative care

Pre‑2026 conservative care (summary)Trial of one or more medications (NSAIDs, acetaminophen), epidural steroid injection as appropriate, and supervised physical therapy (>=3 visits, >75% attendance; at least half in person)

Effective Jan 1, 2026 requirementConservative treatment must include combination of medication and physical therapy and at least two or more medication classes when applicable

Physical therapy specificsSupervised PT with >75% attendance, minimum 3 visits, with at least half in‑person sessions

Lumbar decompression surgeries — definition list for included procedures

Included procedures (examples)Laminectomy, laminotomy (hemilaminectomy), facetectomy, foraminotomy, microdiscectomy and related decompressive procedures

Representative CPT codesExamples include 63011, 63030, 63035, 63042, 63056, 63057

Clinical indicationProcedures performed to decompress spinal cord, cauda equina, or nerve roots for stenosis or herniation when criteria are met

Lumbar arthrodesis and instrumentation — definition list for included procedures and codes

Included fusion proceduresAnterior, posterior, posterolateral, and interbody fusion techniques and associated fixation/instrumentation

Representative CPT codesExamples include 22533–22534, 22612–22634, 22800–22859 (instrumentation and interbody device insertion codes)

Clinical contextArthrodesis and instrumentation codes apply when fusion criteria in the policy statements are satisfied

Myerding Grading for spondylolisthesis — grading scale reference

Grade I~25% slip forward (25% of vertebral body has slipped forward)

Grade II25%–49% slip forward

Grade III50%–74% slip forward

Grade IV75%–99% slip forward

Grade V (spondyloptosis)Complete anterior displacement (vertebral body has completely fallen off)