CurrentPremera BluecrossPolicy 7.01.551

Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy, Laminectomy in Adults

Defines medical necessity, site-of-service considerations, documentation requirements, and coding for elective lumbar decompression surgeries in individuals aged 19 and older for Premera Bluecross.

Policy Summary

PayerPremera Bluecross

PolicyLumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy, Laminectomy in Adults

Policy CodePolicy 7.01.551

Change TypeNo material clinical or coverage changes

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document imaging-confirmed nerve root compression and failure of appropriate conservative care before elective lumbar decompression.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥19applies to individuals aged

6 wksconservative therapy duration

12 mosupporting imaging recency

48 hrsurgent progression timeframe

single-levelACD limited to

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persistent pain threshold (VAS)

Medical Necessity Criteria for Lumbar Decompression

Elective lumbar decompression (discectomy/foraminotomy/laminotomy)

Covered when ALL of the following are met (unless there is rapid neurologic deterioration):

Elective decompression criteria: All other sources of low back pain have been ruled out

Imaging: Lumbar spine MRI or lumbar spine CT myelogram within past 12 months shows nerve root compression corresponding to symptoms and physical exam OR definitive neurologic localization by other means (e.g., selective nerve root injections)12 months

Pain and function: Persistent, debilitating radicular pain daily that limits activities of daily livingVAS >4

Neurologic signs: Neurological deficits or other signs of lumbar root irritation present on physical exam

Examples: reflex change, dermatomal sensory loss, motor weakness, positive straight leg raise

Conservative therapy: Symptoms unresponsive to at least 6 weeks of conservative nonsurgical care including prescription-strength analgesics (anti-inflammatories ± adjuncts), physical therapy, and evaluation/management of cognitive/behavioral/addiction issues>=6 weeks

Includes documentation of compliance

Lumbar laminectomy for spinal stenosis

Covered when ALL of the following are met (unless there is rapid neurologic deterioration):

Exclusion of other causes: All other sources of low back pain have been ruled out

Symptom pattern: Persistent, progressive, debilitating neurogenic claudication present daily that limits activities of daily living

Symptoms may include numbness, tingling, muscle weakness with or without back pain

Imaging: Lumbar spine MRI or lumbar spine CT myelogram within past 12 months shows spinal canal or nerve root compression (lumbar spinal stenosis ± spondylolisthesis) corresponding to clinical findings12 months

Conservative therapy: Symptoms unresponsive to at least 6 weeks of conservative nonsurgical care including prescription-strength analgesics, physical therapy, and evaluation/management of cognitive/behavioral/addiction issues

Urgent neurologic indications

Covered when ANY of the following acute neurologic emergencies are present (rapid progression within 48 hours):

Rapid neurologic deterioration: Rapid (≤48 hours) progression of neurologic impairment such as cauda equina syndrome, foot drop, extremity weakness, saddle anesthesia, or sudden onset bladder or bowel dysfunction<= 48 hours

Urgent surgical indication; prior conservative care not required

Other covered indications for laminectomy

Lumbar laminectomy may also be considered medically necessary for ANY of the following:

Specific indications: Dorsal rhizotomy for spasticity in cerebral palsy

Specific indications: Lumbar spondylolisthesis confirmed by lumbar MRI

Specific indications: Metastatic neoplasm of the spine, benign spinal tumor, or cyst causing nerve root or spinal cord compression with corresponding neurologic deficit confirmed by lumbar MRI

Specific indications: Spinal infection, spinal injury (e.g., epidural hematoma or foreign body), or spinal trauma (e.g., fracture with displaced fragment, vertebral dislocation with instability, locked facets) confirmed by lumbar MRI

Standard surgical coverage criteria

Covered when ALL of the following are met

Symptom severity and impact: Persistent debilitating pain defined as VAS > 4 on a daily basis AND documented impact on activities of daily living despite optimal conservative nonsurgical therapyVAS > 4

See conservative therapy list

Conservative therapy trial: Documented trial, failure, or contraindication to appropriate conservative interventions such as at least 6 weeks of activity modification, oral analgesics/anti-inflammatories, physical therapy, chiropractic manipulation, and/or epidural steroid injections>=6 weeks activity modification typical

Except for surgical emergencies

Imaging confirmation: Radiologically confirmed lumbar spine abnormality on MRI or CT with myelogram within the past 6 months

Annular closure device (ACD) criteria

Covered when ALL of the following are met for annular closure device placement

Device and indication: Use of a bone-anchored annular closure device (Barricaid) following lumbar discectomy to reduce reherniation in individuals with large annular defectsAnnular defects >= 6 mm

Device is FDA approved and intended for single-level use between L4 and S1

Level restriction: Procedure performed at a single level between L4 and S1L4-S1 only

Performed only at a single level; annular defect measurements must be documented

Lumbar discectomy

Discectomy — covered when ALL of the following are met

Discectomy coverage: Individual has lumbar herniated disc with radiculopathy AND symptoms are rapidly progressing or refractory to conservative careconservative care >= 6 weeks

Evidence supports probable short-term benefit and improvement in net health outcome

Lumbar laminectomy

Laminectomy — covered when ALL of the following are met

Laminectomy for spinal stenosis: Individual has lumbar spinal stenosis with spinal canal or nerve root compression AND failed conservative treatmentconservative care >= 8 weeks or severe/progressive symptoms warranting earlier surgery

RCTs show superiority to nonoperative care with sustained benefit; laminectomy may also be medically necessary for space-occupying lesions

Space-occupying lesion indication

Laminectomy for space-occupying lesions

Space-occupying lesions: Presence of a space-occupying lesion of the spinal canal causing compression

Clinical input and standard of care support laminectomy as medically necessary for these lesions

Annular closure device

Annular closure device (ACD) use — covered when ALL of the following are met

ACD (Barricaid) criteria: Primary discectomy at a single level (L4–L5 or L5–S1) AND large annular defect post-discectomy (4–6 mm tall by 6–10 mm wide)single level between L4 and S1; annular defect size as specified

RCTs show reduced reherniation/reoperation but evidence limitations exist; device has FDA approval for these indications

Medical necessity and investigational devices

Covered when ALL of the following are met (policy-level summary from history and statements)

General medical necessity: Lumbar decompression surgery may be considered medically necessary when applicable policy criteria are met, including appropriate diagnostic imaging and clinical correlation

Full, specific criteria (e.g., symptom duration, failure of conservative therapy, imaging findings) are specified in other sections of the policy

Device-specific stance: Use of a bone-anchored annular closure device (ACD) to repair an annular defect is considered investigational

Investigational statement added 05/01/23 as noted in policy history

The policy states that use of an annular closure device (ACD) following lumbar discectomy is considered investigational. The source document explicitly lists an ACD (for example, Barricaid) under investigational procedures and notes a policy-level investigational statement added 05/01/23 indicating use of a bone-anchored ACD to repair an annular defect is considered investigational.

Several alternative discectomy techniques (including laser discectomy, radiofrequency coblation / nucleoplasty, automated percutaneous discectomy, automated endoscopic discectomy, intradiscal electrothermal annuloplasty, and intradiscal radiofrequency therapy) are identified in the policy as procedures without high-quality comparative trials versus standard discectomy and therefore are not considered true alternatives for coverage decisions.

The policy references NICE IPG506 (2014), which concluded that evidence on insertion of annular disc implants at lumbar discectomy is limited in quantity and quality and recommends the procedure only be performed with special arrangements for clinical governance, consent, and audit or research.

A historical policy update (05/01/23) added an explicit statement that the use of a bone-anchored annular closure device (ACD) to repair an annular defect is considered investigational.

Lumbar spine decompression surgery is considered not medically necessary when there is no documented clinical indication and there are no confirmatory physical examination findings and radiologic studies that meet the policy criteria.

Because many disc herniations improve over time, the policy indicates that surgery for herniations expected to improve without meeting criteria for persistent debilitating pain, failed conservative therapy, or urgent neurologic deterioration would not be supported; only a subset with persistent or rapidly progressive symptoms are candidates for operative intervention.

Use of an annular closure device is limited to the specified indications in the policy. Procedures using an ACD outside those indications (for example, different annular defect sizes, multilevel procedures, or levels outside L4–S1) are not supported by sufficient evidence and therefore are not covered.

The policy history records prior editorial revisions and clarifications. Notably, the 2014 history entries included wording refinements to not medically necessary statements for clarity; later history notes document coding and investigational-policy edits (including re-addition/removal of HCPCS C9757 and the 05/01/23 investigational ACD statement). These historical entries clarify the evolution of the policy's NMN and investigational language.

Procedure, HCPCS and Place-of-Service Codes

Coding for lumbar decompression procedures and related devicesmixed

22899	Unlisted procedure, spine (when used for repair of annular defect with implantation of bone anchored annular closure device, following lumbar discectomy).
63005	Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy; lumbar, 1-2 segments.
63012	Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression for spondylolisthesis, lumbar (Gill type).
63017	Laminectomy with exploration/decompression, more than 2 vertebral segments; lumbar.
63030	Laminotomy (hemilaminectomy) with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar.
63032	Laminotomy (hemilaminectomy) with decompression and excision of herniated disc; with repair of annular defect by implantation of bone-anchored annular closure device, including all imaging guidance; 1 interspace, lumbar (new code effective 01/01/26).
63035	Laminotomy (hemilaminectomy) with decompression; each additional interspace (list separately).
63042	Laminotomy with decompression, reexploration, single interspace; lumbar.
63044	Laminotomy with decompression, reexploration, each additional lumbar interspace (list separately).
63047	Laminectomy, facetectomy and foraminotomy, single vertebral segment; lumbar.

1–10 of 19

1/2

Place of Service (Professional Claims Codes)mixed

19	Off-Campus-Outpatient Hospital
21	Inpatient Hospital
22	On Campus-Outpatient Hospital
24	Ambulatory Surgical Center

Regulatory/Product codesmixed

FDA product code QES

Product code for Barricaid annular closure device

HCPCS codes referenced historicallyHCPCS

C9757

HCPCS code referenced in policy history; added/removed historically and moved between policies

CPT codes addedCPT

63032

CPT code added effective January 1, 2026 (coding update noted)

inv-25: Persistent Debilitating Pain (VAS)

DefinitionPersistent, debilitating daily pain defined as a visual analog scale (VAS) score > 4 with documented impact on activities of daily living despite optimal conservative nonsurgical therapy

Documentation requiredMedical record must show VAS > 4 on a daily basis and describe limitations in ADLs despite conservative care

Context in coverage criteriaUsed as a symptom-severity threshold for elective lumbar decompression and related procedures

inv-26: Imaging recency (MRI/CT myelogram within 12 months)

Imaging requirementLumbar spine MRI or lumbar spine CT scan with myelogram performed within the past 12 months showing nerve root compression corresponding to symptoms and exam (or definitive neurologic localization by other means)

Prior Authorization, Documentation, and Denial Triggers

Prior Authorization

Prior authorization required for elective lumbar decompression and site of service review

Elective lumbar decompression procedures (single- and multi-level decompressions with/without single-level fusion) require pre-service review; providers must submit documentation that supports appropriate site-of-service selection for medical necessity review.

Includes review of site of service (off-campus outpatient, on-campus outpatient, ambulatory surgical center, inpatient).
Inpatient site of service is considered medically necessary only when clinical risk factors are present.

Prior Authorization

Prior authorization for ACD and imaging

Prior authorization is required for annular closure device placement following discectomy; submissions must include imaging and meet device indication limitations (single-level L4–S1 and typical annular defect size ≥ 6 mm).

ACD (Barricaid) intended for single-level use between L4 and S1.
ACD generally used to close annular defects ≥ 6 mm; include MRI/CT-myelogram within 6 months when applicable.

Clinical Background and Scope

Background: Decompression procedures (discectomy, foraminotomy, laminotomy, and laminectomy) remove disc material, bone, and/or soft tissue compressing neural elements to relieve radiculopathy or neurogenic claudication. Indications include persistent, debilitating radicular pain or functional limitation despite appropriate conservative care, and urgent neurologic emergencies such as cauda equina or rapidly progressive motor deficits. The policy supports surgery when clinical findings correlate with imaging-confirmed nerve-root or spinal-canal compression and when conservative therapy has failed or when rapid neurologic deterioration is present.

Definitions and Procedure Descriptions

inv-50: Microdiscectomy definition

DefinitionMicrodiscectomy is a discectomy using a small surgical incision and operating microscope to directly visualize and remove disc material; disc removal must be performed under direct visualization to qualify

Technique notesMay use tubular retractors to improve visualization; adjunctive endoscopy may be used to localize the operative site but disc removal must be under direct microscopic visualization

Contrast to endoscopic approachesMicrodiscectomy differs from endoscopic procedures where indirect visualization is used—direct visualization is required for the microdiscectomy definition

inv-51: Radiculopathy definition

DefinitionRadiculopathy is a clinical syndrome of leg‑radiating pain (below the knee), dermatomal numbness or tingling, and motor weakness associated with nerve root compression

Policy Revisions and Historical Notes

2014-01-14policy revision

Replaced prior policy and revised lumbar discectomy MRI criterion to require nerve root compression corresponding to symptoms and exam or definitive neurologic localization (e.g., selective nerve root injections); expanded neurologic deficits language to include alternative signs such as a positive leg raise test.

2014-02-10policy revision

Replaced policy statement: removed cauda equina syndrome as a separate indication because it was encompassed by rapid progression language; added lumbar spine CT myelogram to diagnostic imaging criteria and added selective nerve root injections to acceptable diagnostic tests.

2014-04-04

Policy Summary

PayerPremera Bluecross

PolicyLumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy, Laminectomy in Adults

Policy CodePolicy 7.01.551

Change TypeNo material clinical or coverage changes

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document imaging-confirmed nerve root compression and failure of appropriate conservative care before elective lumbar decompression.

SourceLink

On This Page

Includes documentation of compliance

Include selective nerve root injection report if applicable

Alternative diagnostic supportSelective nerve root injection report may be used if applicable to establish neurologic localization

DocumentationRadiologist's report of the MRI or CT-myelogram must be included in the record

inv-27: Rapid neurologic progression timeframe

TimeframeRapid neurologic progression defined as progression occurring within 48 hours or less (≤ 48 hours)

Examples of urgent findingsCauda equina syndrome, foot drop, extremity weakness, saddle anesthesia, sudden onset bladder or bowel dysfunction

Coverage implicationIf rapid progression (≤48 hours) is present, surgery may be considered without prior conservative therapy

inv-28: Imaging age / Annular defect size (MRI/CT-myelogram 6 months; ACD ≥ 6 mm typical)

Imaging age for ACD prior authWhen seeking annular closure device placement, lumbar spine MRI or CT-myelogram should be available within the past 6 months

Typical annular defect size for ACDAnnular closure devices are generally used for annular defects ≥ 6 mm

Level restriction for ACDDevice intended for single-level use between L4 and S1

inv-29: Annular defect size for ACD (4-6 mm tall x 6-10 mm wide)

Specified defect dimensionsAnnular defect size indicated for ACD (Barricaid) is approximately 4–6 mm tall by 6–10 mm wide

Regulatory descriptionFDA-approved Barricaid is indicated for large annular defects between 4–6 mm tall and 6–10 mm wide following primary discectomy at a single level between L4 and S1

Clinical guidanceISASS and FDA descriptions specify these dimensions when considering bone‑anchored annular closure device placement

Prior Authorization

Authorization: conservative care, imaging, and device-specific documentation

Include imaging-confirmed nerve root compression or definitive neurologic localization, clinical documentation of failed conservative care duration or progressive neurologic deficit, and device-specific details (level and annular defect size) in the prior authorization submission.

Imaging should correlate with symptoms and exam (nerve root compression) or include selective nerve root injection report if used.
For ACD, document single-level location (L4–S1) and annular defect measurements consistent with device indications.

Prior Authorization

Prior authorization and notification

Follow Premera's pre-service notification and prior authorization processes; supply required diagnostic documentation with pre-service requests for coverage decisions.

Providers should use Premera's pre-service request process and include diagnostic imaging and test reports.

Step Therapy

Conservative therapy requirement (≥6 weeks before elective decompression)

Before elective decompression (when not urgent), document a trial and failure of at least 6 weeks of conservative nonsurgical care including prescription-strength analgesics, physical therapy, and management of cognitive/behavioral/addiction issues.

Conservative care must include anti-inflammatory medications (± adjuncts) and at least 6 weeks of physical therapy or documentation why PT was not tolerated.
Document compliance with conservative treatment.

Documentation Required

Conservative management prerequisite — document failure of specified conservative care measures

Document failure of conservative measures prior to surgery except in surgical emergencies; list conservative interventions tried, durations, and responses in the medical record.

Include activity modification for at least 6 weeks, oral analgesics/anti-inflammatories, physical therapy, chiropractic manipulation, and epidural steroid injections when applicable.
Record reasons for contraindication or intolerance when therapies were not attempted.

Step Therapy

Conservative care prior to surgery — 6 weeks discectomy; 8 weeks laminectomy

Policy supports a trial of nonoperative care prior to surgery: generally 6 weeks for discectomy and 8 weeks for laminectomy unless severe or rapidly progressive neurologic deficits warrant earlier intervention.

Discectomy: evidence supports use after failure of usual care for 6 weeks.
Laminectomy: evidence supports superiority after 8 weeks of failed conservative treatment; earlier surgery acceptable for severe/progressive deficits.

Note

Step therapy / conservative care (historical)

Historical policy revisions addressed conservative care and imaging timelines; ensure current conservative treatment requirements and imaging timelines are met per the latest policy statements.

Past revisions clarified MRI sub-bullets and inclusion of selective nerve root injections in diagnostic workup.

Documentation Required

Required documentation to support medical necessity

Medical records must include comorbid physical and psychological conditions, prior back surgery history, details of conservative interventions (trials, failures, durations), physical exam findings, and radiology reports of lumbar MRI or CT-myelogram within the past 12 months (or selective nerve root injection results if applicable).

List specifics of conservative nonoperative interventions tried and failed, including duration and compliance.
Attach radiologist report of MRI or CT-myelogram within past 12 months; include selective nerve root injection report if used for localization.

Documentation Required

Pain severity and functional impact documentation (VAS >4, ADL impact)

Document persistent debilitating daily pain defined as VAS > 4 with impact on activities of daily living despite optimal conservative nonsurgical therapy to support medical necessity.

Record visual analog score and evidence of ADL limitation.
Demonstrate that pain persists despite documented conservative therapy.

Documentation Required

Required clinical documentation (history, prior surgeries, conservative interventions tried)

Include comprehensive clinical documentation: medical history with comorbidities, prior back surgeries, physical exam findings demonstrating neurologic deficits or root irritation, and detailed records of conservative nonoperative interventions tried and their durations.

Document reflex changes, dermatomal sensory loss, motor weakness, or positive leg-raising test when present.
Specify durations of activity modification, analgesic trials, physical therapy, and injections.

Documentation Required

Annular closure device documentation (single-level L4–S1; defect measurements)

For annular closure device procedures, document single-level placement at L4–L5 or L5–S1 (L4–S1) and annular defect measurements consistent with device indications (approximately 4–6 mm tall by 6–10 mm wide).

Confirm primary discectomy at a single level and measured annular defect dimensions after discectomy.
Note FDA indication and ISASS recommendations specifying 4–6 mm by 6–10 mm defect size and single-level L4–L5 or L5–S1.

Documentation Required

Required documentation (historical notes)

Policy history notes documentation requirements added in prior revisions (e.g., 2018); provide diagnostic imaging and test reports that demonstrate nerve root compression corresponding to symptoms or definitive neurologic localization.

Include selective nerve root injection reports if they were used for diagnostic localization.
Supply prior revision–referenced documentation when applicable.

Denial Risk

Lack of documented clinical and radiologic indication may lead to NMN determination

If no clinical indication and no confirmatory physical and radiologic findings meeting policy criteria are documented, lumbar spine decompression surgery is considered not medically necessary and may be denied.

Ensure documentation of both clinical findings and imaging that correspond to policy criteria to avoid denial.

Denial Risk

Inpatient site-of-service not justified without documented risk factors

An inpatient hospital site-of-service for elective procedures is not medically necessary when the site-of-service risk criteria are not met; document clinical risk factors if inpatient admission is requested.

Document ASA class, cardiopulmonary, hepatic, renal, or other risks that justify inpatient level of care per policy criteria.

Documentation Required

Imaging recency — MRI/CT-myelogram within past 6 months required for diagnostic confirmation

Lack of a radiologically confirmed lumbar spine abnormality on MRI or CT-myelogram within the past 6 months may trigger denial; include a report of imaging (or selective nerve root injection) within that timeframe when required for diagnostic confirmation.

Diagnostic testing section specifies imaging within the past 6 months for radiologic confirmation.
Attach radiologist report demonstrating nerve root compression corresponding to clinical findings.

Denial Risk

Conservative therapy / symptom severity absence may lead to denial

Absence of documented trial and failure of appropriate conservative therapy or lacking documentation of persistent debilitating pain may lead to denial of the surgical request.

Demonstrate trials of activity modification, prescription analgesics, physical therapy, and other conservative measures as applicable.
Document VAS and ADL impact despite optimal nonsurgical therapy.

Denial Risk

Conservative care and neurologic deficit documentation — duration requirements

Failure to document prior trial of conservative care of appropriate duration (6 weeks for discectomy; 8 weeks for laminectomy) or lack of documentation of progressive or severe neurologic deficit may trigger denial.

Specify duration of conservative care and the reason for earlier surgery if performed (e.g., severe or progressive neurologic deficits).

Denial Risk

Denial triggers — unmet medical necessity criteria

Requests may be denied if policy criteria for medical necessity are not met; ensure all applicable policy criteria (imaging, pain severity, conservative care, neurologic findings, device-specific indications) are documented in the submission.

Use policy criteria as checklist when preparing prior authorization and medical records to reduce denial risk.

Typical history findings

Pain radiating down the back of the leg to below the knee; numbness and tingling in a dermatomal distribution

Typical exam findingsPositive straight leg raise, loss of deep tendon reflexes corresponding to the affected root, and dermatomal sensory loss

inv-52: Cauda equina syndrome definition

DefinitionCauda equina syndrome (CES) is a surgical emergency caused by compression of the cauda equina nerves, presenting with rapidly progressive neurologic symptoms such as severe bilateral leg pain, motor weakness, new bowel or bladder dysfunction, saddle anesthesia, and absent lower extremity reflexes

EtiologiesCES may be caused by herniated disk, infection, cancer, trauma, or spinal stenosis

Clinical urgencyRapid progression of symptoms necessitates urgent surgical evaluation and management

inv-53: Lumbar laminectomy definition

DefinitionLumbar laminectomy is surgical removal of part or all of the lamina to decompress the spinal cord and nerve roots, commonly performed for lumbar spinal stenosis

Procedure detailsTypically performed under general anesthesia; lamina and possibly inflamed ligaments are removed to relieve compression; may be combined with foraminotomy or fusion if instability is present

Usual settingOften performed as an inpatient procedure though minimally invasive variations exist

inv-54: Laminectomy / Laminotomy / Hemilaminotomy distinctions

LaminectomyRemoval of the whole posterior arch (lamina) of a vertebra, often with resection of inflamed ligaments to decompress neural elements

LaminotomyLimited removal of a portion of the lamina focused on the interlaminar space, preserving more posterior stabilizing structures and avoiding disruption of facet joints

HemilaminotomyRemoval of only one side (left or right) of the lamina, a less invasive approach that limits resection to the affected side

inv-55: Annular closure device (Barricaid) definition

Device descriptionAn annular closure device (Barricaid) is a bone‑anchored implant with a titanium anchor secured to an adjacent vertebral body and a flexible polymer mesh that occludes the annular defect to prevent reherniation

Indication and useFDA-approved to reduce reherniation and reoperation in skeletally mature patients after primary discectomy for posterior or posterolateral herniation at a single level between L4 and S1

Typical defect sizeGenerally used for large annular defects ≥ 6 mm (often specified as 4–6 mm tall by 6–10 mm wide in device labeling and guidance)

inv-56: Rapid progression historical definition

Historical definitionRapid progression historically defined in the policy as progression over 48 hours or less (added in 2016)

Policy implicationThis historical definition underpins the urgent-surgery exception to conservative-treatment requirements

Reference to historyThe history section documents the 2016 addition of the ≤48-hour rapid progression definition

Minor rewording of the not medically necessary policy statement for clarity without changing intent.

2014-12-22interim update

Interim update to related policies and resources; policy statement unchanged.

2021-05-03history entry

Literature review through May 3, 2021 noted and HCPCS code C9757 added to policy history.

2023-12-01coding/editorial updateLatest

Review through May 5, 2023 with references added and minor editorial refinements to policy statements; coding updates noted (e.g., CPT code updates referenced elsewhere).

Historical edits include the 2014 clarifications to diagnostic imaging and neurologic localization language, subsequent coding updates (removal and later re-addition of HCPCS C9757), and the 05/01/23 interim review that added the investigational statement about bone-anchored annular closure devices; these entries document iterative refinements to both clinical and coding statements over time.

Coding history and notes: HCPCS code C9757 was added, removed, and then re-added in policy history entries (noted in 2021–2023 history). The policy also documents a coding update effective 01/01/26 that adds CPT code 63032 for laminotomy with decompression and implantation of a bone-anchored annular closure device.