CurrentPremera BluecrossPolicy 7.01.560

MEDICAL POLICY - 7.01.560 Fusion in Adults

Defines medical necessity criteria, site-of-service rules, documentation requirements, and coding for single-level cervical decompression surgeries and single-level cervical fusions in adults (age ≥19). Prior authorization required for all indicated cervical spine surgeries. Smoking within 6 weeks before elective fusion is a contraindication.

Policy Summary

PayerPremera Bluecross

PolicyMEDICAL POLICY - 7.01.560 Fusion in Adults

Policy CodePolicy 7.01.560

Change TypeMultiple historical coding and criteria updates (2016–2025)

Effective DateDec 15, 2014

Next Review Date

Key ActionPrior authorization review and approval is required for all indications for cervical spine surgery; submit clinical information that supports medical necessity.

POLICY UPDATE CHANGES

Title changed and policy expanded to include posterior cervical fusion, cervical discectomy, and cervical laminectomy (11/01/18).

Diagnostic imaging timeframe changed from 6 months to 12 months (05/01/16).

Requests for fusions >2 levels must be reviewed by a medical director (01/01/17).

Site of service review added to single-level cervical decompression and fusion CPT codes effective Jan 7, 2022.

Multiple CPT codes added effective December 5, 2024 (63001, 63015, 63040, 63043, 63050, 63051, 63075, 63076, 63081, 63265).

Clarified policy statement for cervical discectomy to explicitly require persistent debilitating pain unresponsive to at least 6 weeks of conservative nonsurgical therapy (11/01/25 review).

Single-levelCovered Procedure Scope

>=19Age Population

Coverage Summary

Scope: This policy applies to adults age 19 and older and defines medical necessity, site-of-service rules, documentation requirements, and coding for single-level cervical decompression surgeries and single-level cervical fusions. Policy number: 7.01.560. Effective date (policy header): 2014-12-15; Last review: 2025-10-13.

Covered procedures: the policy reviews and applies to single-level cervical decompression surgeries (e.g., discectomy, laminotomy/laminectomy) and single-level cervical fusions (anterior or posterior) and references the applicable CPT codes in the coding section.

Administrative and clinical rules: prior authorization review and approval is required for all cervical spine surgeries covered by this policy. The policy includes site-of-service review for single-level cervical decompression and fusion procedures. Active cigarette, cigar, or pipe smoking within 6 weeks prior to scheduled (non-emergent) cervical spinal fusion is a contraindication and must be documented as smoking cessation for at least 6 weeks smoke-free prior to elective fusion.

Medical Necessity Criteria

General Scope and Site of Service

Policy applies to adults age 19 and older and covers single‑level cervical decompression surgeries and single‑level cervical fusions; site of service review and prior authorization requirements apply.

ALL of the following

Patient is age 19 or older
Procedure is a single-level cervical decompression surgery or single-level cervical fusion
Prior authorization review and approval is required
Site of service considered medically necessary: off-campus outpatient hospital (code 19), on-campus outpatient hospital (code 22), ambulatory surgical center (code 24); inpatient hospital (code 21) only if increased risk for complications present
Inpatient indicated for anesthesia, cardiovascular, liver, pulmonary, renal or other risks as listed

Inpatient Hospital Medical Necessity for Elective Procedures (Site-of-Service Exceptions)

Inpatient site is medically necessary only when one or more clinical conditions increasing risk for complications are present.

ANY of the following

Anesthesia risk: ASA classification III or higher; personal history of complication of anesthesia; documentation of alcohol dependence or history of cocaine use; prolonged surgery (>3 hours)
Cardiovascular risk: Uncompensated chronic heart failure (NYHA class III or IV); recent myocardial infarction (<3 months); poorly controlled, resistant hypertension (3 or more drugs to control BP); recent cerebrovascular accident (<3 months); increased risk for cardiac ischemia (drug eluting stent <1 year or angioplasty <90 days); symptomatic cardiac arrhythmia despite medication; significant valvular heart disease
Liver risk: Advanced liver disease (MELD Score > 8)

Smoking

Smoking-related contraindications and scope of policy statement.

ALL of the following

Smoking contraindication: Current cigarette, cigar, or pipe smoking within 6 weeks prior to scheduled (non-emergent) cervical spinal fusion is a contraindication
Document smoking cessation for at least 6 weeks prior to scheduled non-emergent fusion
Scope note: Policy does not address smokeless tobacco or nicotine replacement products (e-cigarettes, nicotine gum/lozenges/patches); no studies found regarding their effect on orthopedic surgical outcomes

Anterior Cervical Fusion - Indications (Medically Necessary)

Anterior cervical fusion may be medically necessary when any ONE of the following conditions is present.

ANY of the following

Degenerative cervical spondylosis
Infection of cervical spine requiring decompression or debridement
Ossification of posterior longitudinal ligament (OPLL) at 1 to 3 levels associated with myelopathy
Posttraumatic cervical instability (e.g., unstable anterior column fracture)
Spine fracture and/or dislocation associated with mechanical instability, locked facets, or displaced fracture fragment

Anterior Cervical Fusion - Cervical Radiculopathy

May be considered medically necessary when ALL of the following are met for cervical radiculopathy.

ALL of the following

Clinical requirement: Unremitting radicular pain or progressive weakness secondary to nerve root compression
Conservative therapy: At least 6 weeks of conservative nonsurgical therapy including: prescription-strength analgesics for several weeks (anti-inflammatories ± adjunctive meds such as nerve membrane stabilizers or muscle relaxants if not contraindicated); physical therapy; evaluation and management of associated cognitive, behavioral or addiction issues when present>= 6 weeks
Imaging correspondence: Cervical spine MRI or CT myelogram within past 12 months demonstrates spinal stenosis or nerve root compression at same level as symptoms and physical examWithin past 12 months

Anterior Cervical Fusion - Spondylotic Myelopathy

May be considered medically necessary when ALL of the following are met for spondylotic myelopathy.

ALL of the following

Signs or symptoms of myelopathy (one or more): Upper limb weakness in more than a single nerve root distribution; lower limb weakness; loss of dexterity (e.g., clumsiness of hands); bowel or bladder incontinence; frequent falls; hyperreflexia; Hoffmann sign; increased extremity muscle tone or spasticity; gait abnormality; positive Babinski sign
Imaging requirement: Cervical spine MRI or CT myelogram within past 12 months demonstrates spinal cord compression corresponding to symptoms and exam due to herniated disk, osteophyte, or OPLLWithin past 12 months

Anterior Cervical Fusion - Pseudarthrosis (Failed Union)

May be considered medically necessary when ALL of the following are met for pseudarthrosis (failed union).

ALL of the following

Radiographic or clinical evidence: Radiographic evidence of hardware failure (e.g., fracture or displacement) OR axial neck pain corresponding to level of pseudarthrosis that is unresponsive to at least 6 weeks of conservative nonsurgical therapy
Conservative therapy for pseudarthrosis: Conservative nonsurgical therapy includes prescription-strength analgesics for several weeks (anti-inflammatories ± adjunctive meds), physical therapy, and evaluation/management of cognitive/behavioral/addiction issues when present; unresponsive for at least 6 weeks>= 6 weeks
Imaging non-union: Cervical spine MRI or CT after 12 months since prior spinal fusion demonstrates non-union at same level as symptoms

Anterior Cervical Fusion - Degenerative Adjacent Segment Disease

May be considered medically necessary when ONE or more of the following are met for degenerative adjacent segment disease.

ALL of the following

Adjacent level symptoms: Symptomatic myelopathy corresponding clinically to an adjacent level OR symptomatic radiculopathy corresponding clinically to an adjacent level that is unresponsive to at least 6 weeks of conservative nonsurgical therapy (same conservative elements as above)>= 6 weeks for radiculopathy refractory case
Imaging correspondence: Cervical spine MRI or CT myelogram within past 12 months demonstrates spinal stenosis or nerve root compression at same level as symptoms and examWithin past 12 months

Anterior Cervical Fusion - Acute Cervical Spine Injury

May be considered medically necessary when ALL of the following are met for acute cervical spine injury.

ALL of the following

Clinical acute presentation: Acutely symptomatic cervical radiculopathy or myelopathy is present
Imaging requirement: MRI or other neuroimaging within past 12 months demonstrates pathologic anatomy (e.g., cord or root compression) corresponding to symptomsWithin past 12 months

Posterior Cervical Fusion - Indications (Medically Necessary)

Posterior cervical fusion may be medically necessary when any ONE of the listed conditions is present.

ANY of the following

Atlas and axis fractures
Bilateral locked facets
Cervical instability in an individual with Down syndrome
Cervical instability in skeletal dysplasia or connective tissue disorders
Disruption of posterior ligamentous structures

Posterior Cervical Fusion - Multilevel Spondylotic Myelopathy

May be considered medically necessary for multilevel spondylotic myelopathy when ALL of the following are met; include signs of myelopathy branch.

ALL of the following

Signs or symptoms of myelopathy (one or more): Upper limb weakness in more than a single nerve root distribution; lower limb weakness; loss of dexterity (e.g., clumsiness of hands)

Posterior Cervical Fusion - Symptomatic Unstable Cervical Spondylosis (Radiographic Criteria)

May be considered medically necessary for symptomatic unstable cervical spondylosis when radiographic instability criteria are met.

Radiographic instability criteria: Subluxation > 3.5 mm on static lateral views; sagittal plane angulation > 11 degrees between adjacent segments; more than 4 mm of motion (subluxation) on dynamic views

Posterior Cervical Fusion - Pseudarthrosis

May be considered medically necessary when ALL of the following are met for pseudarthrosis after posterior fusion.

ALL of the following

Radiographic or clinical evidence: Radiographic evidence of hardware failure (e.g., fracture or displacement) OR axial neck pain corresponds to level of pseudarthrosis and is unresponsive to at least 6 weeks of conservative nonsurgical therapy (prescription analgesics, physical therapy, evaluation/management of cognitive/behavioral/addiction issues)>= 6 weeks
Imaging non-union: Cervical spine MRI or CT after 12 months since prior spinal fusion demonstrates non-union at same level as symptoms and exam findings>= 12 months since prior fusion

Posterior Cervical Fusion - Acute Cervical Spine Injury

May be considered medically necessary when ALL of the following are met for acute cervical spine injury.

ALL of the following

Clinical acute presentation: Acutely symptomatic cervical radiculopathy or myelopathy is present
Imaging requirement: MRI or other neuroimaging within past 12 months demonstrates pathologic anatomy corresponding to symptomsWithin past 12 months

Cervical Discectomy (Anterior or Posterior) - Indications (Medically Necessary)

Cervical discectomy may be considered medically necessary for cervical herniated disc when ALL of the following are met.

Clinical presentation requirement

Signs/symptoms present (one or more): Pain radiating into shoulder/arm/hand; numbness and tingling in a dermatomal distribution; muscular weakness in pattern associated with nerve root compression; increased/abnormal reflexes corresponding to affected nerve root level; loss of sensation in a dermatomal pattern
Persistent debilitating pain or progressive myelopathy: Rapidly progressing neurologic deficits OR persistent debilitating neck, back, or arm pain unresponsive to at least 6 weeks of conservative nonsurgical therapy (prescription-strength analgesics for several weeks including anti-inflammatories ± adjunctive meds, physical therapy, evaluation/management of cognitive/behavioral/addiction issues) OR persistent/progressive myelopathy unresponsive to ≥6 weeks conservative therapy>= 6 weeks
Imaging correspondence:

Cervical Discectomy - Not Medically Necessary

When criteria above are not met, discectomy is not covered.

Not medically necessary condition: Cervical discectomy is considered not medically necessary for treatment of a cervical herniated disc if the specified criteria (signs/symptoms, imaging correspondence, and conservative therapy requirements) are not met

Discectomy will likely be denied if required criteria are not met

Cervical Laminectomy - Indications (Medically Necessary)

May be considered medically necessary when ANY of the following are present for cervical laminectomy.

ANY of the following

Fracture/dislocation: Spinal fracture, dislocation, locked facets, or displaced fracture fragment confirmed by imaging (CT or MRI)
Infection: Spinal infection confirmed by imaging (CT or MRI)
Tumor: Spinal tumor confirmed by imaging (CT or MRI)

Cervical Laminectomy - Stenosis or Other Causes of Cord/Root Compression

May be considered medically necessary for stenosis or other causes of cord/root compression when ALL criteria are met.

ALL of the following

Clinical findings (one of the following): Rapidly progressing neurologic deficits OR persistent debilitating pain unresponsive to at least 6 weeks of conservative nonsurgical therapy (prescription-strength analgesics, physical therapy, evaluation/management of cognitive/behavioral/addiction issues) OR signs and symptoms of cervical myelopathy or cord compression such as difficulty with fine hand movements, incoordination, thenar/hypothenar atrophy, diffuse hyperreflexia and bilateral Babinski, decreased sensation/vibration/proprioception at C5 or below, inability to perform tandem walk, bowel/bladder incontinence>= 6 weeks when persistent pain branch applies
Imaging correspondence: MRI or other neuroimaging within past 12 months demonstrates pathologic anatomy corresponding to signs and symptoms (spinal cord compression, nerve root compression and/or myelographic changes)Within past 12 months

Cervical discectomy (including anterior cervical discectomy) - medically necessary

Aggregate covered elements for cervical discectomy (including anterior cervical discectomy).

ALL of the following

Adult population: Individual is an adult
Clinical diagnosis of cervical herniated disc(s) with symptoms of radiculopathy
Symptom course: Symptoms are rapidly progressing or refractory to conservative care (persistent debilitating pain unresponsive to at least 6 weeks of conservative nonsurgical therapy)>= 6 weeks
Clarified policy requires at least 6 weeks of conservative nonsurgical therapy for persistent debilitating pain

Cervical laminectomy - medically necessary

Covered when ALL of the following are met for cervical laminectomy.

ALL of the following

Indications: Cervical spinal stenosis with spinal cord or nerve root compression OR space-occupying lesion(s) of the spinal canal causing nerve root compression
For space-occupying lesions evidence is mostly case series but may be considered medically necessary when no alternative treatment and clinical input supports use
Adult and documentation: Individual is an adult; documentation of medical history, physical findings, and diagnostic imaging demonstrating need for cervical spine surgery; most cases require imaging showing spinal stenosis and nerve root or cord compressionWithin past 12 months for imaging

Cervical fusion (including anterior cervical fusion) - coverage considerations

Coverage/consideration for cervical fusion including conservative therapy guidance and documentation requirements.

ALL of the following

Conservative therapy guidance: Symptoms have persisted despite an initial short course (generally 4-6 weeks) of self-care and conservative management; comprehensive nonoperative approach (ICER/guidelines) is first-line4-6 weeks guidance
Exam and imaging: Physical examination and diagnostic imaging indicate neural compression at the appropriate levelImaging within past 12 months
Documentation supports need for fusion; submit medical history, physical findings, diagnostic imaging; prior authorization required
Requests for fusions >2 levels require medical director review

Indications with insufficient evidence

Indications where evidence is insufficient or low quality to determine comparative benefit.

ANY of the following

Space-occupying lesions evidence: Use of cervical laminectomy for space-occupying lesions — evidence insufficient from comparative studies (case series only)
May be considered medically necessary when no alternatives and clinical input supports use
Other low quality evidence indications: Other indications lacking high-quality comparative evidence where uncontrolled series do not permit efficacy determination

Coding

Covered CPT codes for cervical fusion, laminectomy, laminotomy, discectomy and related proceduresCPTCovered

22551	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2.
22552	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure).
22554	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2.
22585	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure).
22600	Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment.
22614	Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace (List separately in addition to code for primary procedure).
63001	Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, 1 or 2 vertebral segments; cervical.
63015	Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, more than 2 vertebral segments; cervical.
63020	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical.
63040	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical.

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Procedure CPT codes referenced/added historically (professional surgical codes)CPT

22551	Anterior cervical decompression and fusion (historical/site-of-service review added to select codes effective Jan 7, 2022).
22554	Additional levels anterior cervical fusion (historical reference).
22600	Posterior or posterolateral arthrodesis, single interspace (historical reference; coding updated 01/01/22).
22614	Posterior or posterolateral arthrodesis, each additional interspace (historical).
63020	Laminotomy (hemilaminectomy) with decompression; 1 interspace, cervical (historical reference/site-of-service review noted).
63045	Laminectomy, facetectomy and foraminotomy, single vertebral segment; cervical (historical reference/site-of-service review noted).
63048	Laminectomy, facetectomy and foraminotomy, each additional vertebral segment, cervical — added 07/01/24 (coding update).
63001	Added to policy effective December 5, 2024 (coding update).
63015	Added to policy effective December 5, 2024 (coding update).
63040	Added to policy effective December 5, 2024 (coding update).

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Provider Actions & Administrative Requirements

Prior Authorization

Prior authorization required

Prior authorization review and approval is required for all cervical spine surgeries described in this policy. Submit medical documentation that supports the medical necessity of the requested procedure at the time of prior authorization submission.

Documentation Required

Required clinical documentation

Submit the following clinical documentation with the prior authorization request to support medical necessity:

Comorbid assessment and relevant preoperative risk information (e.g., ASA class, cardiac/pulmonary/renal/liver status)
History of prior back or cervical spine surgery, if any
Documentation of trial, failure, or contraindication to conservative nonsurgical interventions (see Conservative therapy requirement block)

Background, Evidence, and Definitions

Background: Cervical fusion joins vertebrae to stabilize the neck and relieve pain and/or neurologic dysfunction from instability or compressive pathology. Discectomy removes one or more intervertebral discs to decompress affected nerve roots; anterior cervical discectomy is the most common approach and may be performed with or without fusion. Laminectomy removes the lamina to decompress the spinal cord, while laminotomy/hemilaminotomy are more limited, partial-lamina decompressions. Surgical variations include anterior versus posterior approaches, fusion with instrumentation or bone graft, laminoplasty, foraminotomy, and minimally invasive or microendoscopic techniques.

Intended outcomes and complications: These procedures aim to relieve nerve or cord compression, reduce pain, improve function, and prevent neurologic deterioration. Potential complications across procedures include infection, bleeding, dural puncture/cerebrospinal fluid leak, nerve or spinal cord injury, hardware failure or displacement, nonunion/pseudarthrosis (fusion), adjacent-segment disease, and the possible need for additional surgery.

Rationale and utilization: The policy is based on evidence and utilization in the adult population. Evidence summaries indicate fusion and discectomy may provide faster short-term symptomatic relief versus conservative care but that long-term outcomes (around 12 months) are often comparable; cervical laminectomy evidence is supported by systematic reviews and nonrandomized studies and by extrapolation from lumbar data for some indications. Consequently, a comprehensive nonoperative approach is recommended as first-line therapy for chronic cervical pain, and surgery is generally considered after failure of appropriate conservative care.

Label	Summary
Effectiveness of fusion vs conservative care
Faster short-term relief for fusion but comparable outcomes at 12 months
Cervical discectomy evidence
Two small RCTs and a systematic review show short-term symptom and disability improvement; long-term outcomes similar to conservative care
Laminectomy evidence
Systematic reviews and nonrandomized comparative studies; lack of high-quality comparative evidence for some indications but outcomes comparable to lumbar stenosis literature; case series for space-occupying lesions
Smoking effect
Smoking increases risk of nonunion/pseudarthrosis in cervical and lumbar fusion procedures
RCTs for cervical discectomy
Two small RCTs and systematic review showing short-term symptom/disability benefit; long-term outcomes similar to conservative care
ICER 2013
ICER found fusion provides faster short-term relief but comparable outcomes at 12 months vs conservative care and reported higher complication rates with fusion

Term	Definition
Positive Babinski sign
A reflex response consisting of extension of the big toe when the sole of the foot is stroked
Cervical myelopathy
Loss of function in the upper and lower extremities due to compression of the spinal cord within the neck
Cervical radiculopathy
Persistent neck pain that radiates into the shoulder/arm in a dermatomal pattern or progressive weakness from nerve root irritation/injury
Cervical spondylosis
Abnormal wear of the cartilage and bones in the cervical vertebrae, including discs and facet joints; may result in bone spurs
Pseudarthrosis
When bones fail to fuse after spinal fusion surgery (lack of union)
Smoking cessation (policy)
Smoking cessation for at least 6 weeks prior to scheduled (non-emergent) surgery applies to smoking cigarettes, cigars, and pipe smoking of tobacco
OPLL
Ossification of the posterior longitudinal ligament

Medicare Determinations

Determination Type	Number	Effective Date	Notes
No national coverage determination


No national coverage determination (NCD)

Not Medically Necessary / Limitations

Cervical Discectomy - Not Medically Necessary; Indications with insufficient evidence

Surface explicit not-covered or insufficient-evidence scenarios; do not duplicate denial callouts elsewhere.

ANY of the following

Discectomy not covered when criteria unmet: Cervical discectomy is not medically necessary for treatment of a cervical herniated disc if required criteria (signs/symptoms, imaging correspondence, conservative therapy requirements) are not met
Do not duplicate other denial callouts
Insufficient evidence scenarios: Use of laminectomy for space-occupying lesions and other indications where only uncontrolled series exist — evidence insufficient to determine efficacy compared with alternatives
Policy allows consideration when no alternatives and clinical input supports use

Revision History

11/01/18title_change_and_expansion

Material change: Title changed and policy expanded to include posterior cervical fusion, cervical discectomy, and cervical laminectomy; chiropractic care added as a nonoperative therapy; CPT codes 22600, 63020, and 63045 added.

05/01/16diagnostic_imaging_timeframe_change

Diagnostic imaging timeframe changed from 6 months to 12 months (non-material change).

01/01/17multi_level_fusion_review_requirement

Material change: Requests for fusions of more than 2 levels must be reviewed by a medical director.

Policy Summary

PayerPremera Bluecross

PolicyMEDICAL POLICY - 7.01.560 Fusion in Adults

Policy CodePolicy 7.01.560

Change TypeMultiple historical coding and criteria updates (2016–2025)

Effective DateDec 15, 2014

Next Review Date

Key ActionPrior authorization review and approval is required for all indications for cervical spine surgery; submit clinical information that supports medical necessity.

On This Page

Step Therapy

Conservative therapy requirement

Elective fusion for cervical radiculopathy, adjacent segment disease, or after discectomy requires failure of at least 6 weeks of conservative nonsurgical therapy prior to authorization for elective surgery.

Conservative therapy components must include: prescription-strength analgesics for several weeks at a dose sufficient to induce a therapeutic response (e.g., anti-inflammatory agents ± adjunctive agents such as nerve membrane stabilizers or muscle relaxants, if not contraindicated)
Structured physical therapy
Evaluation and appropriate management of associated cognitive, behavioral, or addiction issues when present

Denial Risk

Discectomy denial condition

Cervical discectomy or fusion requests that do not meet required criteria — including lack of corresponding signs/symptoms, absence of imaging correlating to the clinical findings, or insufficient trial of conservative therapy — will be considered not medically necessary and are likely to be denied.

Billing Rule

Site of service review for certain CPT codes

Historic site-of-service review applies to certain CPT codes for cervical spine procedures; providers should be aware of site-of-service review requirements for applicable dates of service.

Affected CPT codes include: 22551, 22554, 22600, 63020, 63045
Historic site-of-service review effective January 7, 2022 — confirm applicable site-of-service rules for the date of service being billed