ModifiedSecurity Health Plan of Wisconsin, Inc.Policy N/A

Back Surgical Procedures: Cervical and Thoracic Spinal Levels - Inpatient and Outpatient Settings

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This policy governs coverage, medical-necessity review, precertification, and exclusions for cervical and thoracic back surgical procedures in inpatient and outpatient settings. Requirements vary by product, including Commercial, Medicaid, Medicare Advantage, TPA, and Family Health Center products.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyBack Surgical Procedures: Cervical and Thoracic Spinal Levels - Inpatient and Outpatient Settings

Policy CodePolicy N/A

Change TypeModified

Effective DateFeb 1, 2026

Last ReviewJan 5, 2026

Next Review DateMay 8, 2023

Key ActionObtain prior authorization through eviCore before performing covered spinal surgery for Commercial members.

SourceLink

POLICY UPDATE CHANGES

Align, Align DSNP, and Great Plains Medicare Advantage health plans were added to the policy.

Criteria for intervertebral body fusion devices, including synthetic spine cages and spacers, were removed from this policy.

The policy added a definition and revised ForwardHealth language.

Cervical and thoracic provocative discography and percutaneous disc decompression remain experimental or investigational.

Information on erector spinae plane blocks was removed from this policy.

Laminectomy criteria were removed because the associated codes are reviewed in InterQual.

Cervical and thoracic back surgical procedure review transitioned to InterQual.

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ModifiedSecurity Health Plan of Wisconsin, Inc.Policy N/A

Back Surgical Procedures: Cervical and Thoracic Spinal Levels - Inpatient and Outpatient Settings

Customize your policy alerts

Sign up for all security_health_plan_of_wisconsin_inc policy alerts

Know when security_health_plan_of_wisconsin_inc releases new policies or updates existing guidance.

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Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyBack Surgical Procedures: Cervical and Thoracic Spinal Levels - Inpatient and Outpatient Settings

Policy CodePolicy N/A

Change TypeModified

Effective DateFeb 1, 2026

Last ReviewJan 5, 2026

Next Review DateMay 8, 2023

Key ActionObtain prior authorization through eviCore before performing covered spinal surgery for Commercial members.

SourceLink

POLICY UPDATE CHANGES

Align, Align DSNP, and Great Plains Medicare Advantage health plans were added to the policy.

Criteria for intervertebral body fusion devices, including synthetic spine cages and spacers, were removed from this policy.

The policy added a definition and revised ForwardHealth language.

Cervical and thoracic provocative discography and percutaneous disc decompression remain experimental or investigational.

Information on erector spinae plane blocks was removed from this policy.

Laminectomy criteria were removed because the associated codes are reviewed in InterQual.

Cervical and thoracic back surgical procedure review transitioned to InterQual.

All agesPrior authorization requirement

2 or moreConservative-treatment regimens generally required

6 weeksMinimum conservative-management duration

5Thermal intradiscal procedures identified as unproven

3Medicare Advantage plans added effective 1/1/2026

InterQualCurrent review source for applicable criteria

Medical Necessity and Coverage Criteria

Conservative medical management

Conservative medical management is generally required for all spinal surgical procedures unless a qualifying exception applies.

Conservative-management pathway

Standard conservative treatment
- Required treatment trial: The member has complied with two or more conservative-treatment regimens for at least 6 weeks.At least 2 regimens for at least 6 weeks
  Regimens may include interdisciplinary rehabilitation, physical therapy, an active exercise program, spinal manipulation, cognitive-behavioral therapy, or pain management with appropriately dosed medications and/or injections.
Waiver conditions: At least one condition permitting waiver of the conservative-treatment trial is present.At least 1 condition
Qualifying conditions are spinal cord compression; stenosis causing cauda equina syndrome; stenosis causing myelopathy; stenosis causing severe weakness graded 4 or less on the MRC scale; severe stenosis associated with instability, defined as dynamic excursion greater than 1 mm translation or greater than 5 degrees angulation at an interspace; or progressive neurological deficit on serial examinations.

Instrumentation removal

Removal of anterior or posterior instrumentation is medically necessary when at least one of the following conditions is met.

Instrumentation removal indications

Complete and stable correction: The correction is complete and stable.
Growing juvenile: The patient is a growing juvenile.
Instrumentation complication: The instrumentation causes a complication, such as infection or pain.

Spinal neurostimulator procedures

Revision or replacement of spinal neurostimulator components is medically necessary when both conditions are met.

Neurostimulator component revision or replacement

Stimulator medical necessity: The individual meets medical-necessity criteria for the spinal stimulator.
Unrepairable, out-of-warranty component: The existing stimulator or battery/generator is no longer under warranty and cannot be repaired.

Cervical and thoracic provocative discography is considered experimental and investigational because the available evidence is insufficient to support its effectiveness.

Percutaneous disc decompression is considered experimental and investigational under this policy.

Thermal intradiscal procedures (TIPs) are unproven and not medically necessary for treating discogenic pain. TIPs include cervical intradiscal radiofrequency lesioning, intradiscal biacuplasty or intervertebral disc biacuplasty/cooled radiofrequency, nucleoplasty, percutaneous intradiscal radiofrequency thermocoagulation, and radiofrequency annuloplasty.

Bone marrow aspiration for bone grafting in spine surgery is considered experimental and investigational based on the applicable technology assessment.

Computer-assisted navigational robotic systems, including systems such as Mako, OrthAlign, and BrainLab, are not considered experimental or investigational. However, their use is not separately reimbursed.

For Family Health Center members, surgical services performed in an inpatient, outpatient surgery, observation, or ambulatory surgical setting are not covered.

Services that do not meet the policy's stated clinical criteria are denied as not medically necessary. Services not listed with applicable clinical criteria are considered experimental or investigational.

Thermal intradiscal procedures are unproven and not medically necessary for treating discogenic pain. The procedures include cervical intradiscal radiofrequency lesioning, intradiscal biacuplasty, nucleoplasty, percutaneous intradiscal radiofrequency thermocoagulation, and radiofrequency annuloplasty.

Authorization, Review, and Provider Requirements

Prior Authorization

Commercial Prior Authorization Required

Prior authorization is required through eviCore for Commercial members of all ages. Start the request with eviCore, and contact the Health Plan for precertification when required.

eviCore: 888-444-6185 or www.evicore.com
Health Plan precertification: 1-800-991-8109
Fax requests to 715-221-6616

Prior Authorization

BadgerCare Plus and Medicaid SSI Authorization

For BadgerCare Plus and Medicaid SSI requests performed in an outpatient, ambulatory surgery center, or for initial inpatient services, prior authorization is required through eviCore for all ages. For concurrent inpatient reviews, request precertification from the Health Plan.

eviCore: 888-444-6185 or www.evicore.com
Concurrent inpatient review: call 1-800-991-8109 or fax 715-221-6616

Clinical Background

Back surgery is commonly performed for herniated discs or spinal stenosis and may also be indicated for fracture, infection, or tumor involving spinal elements. Spinal decompression relieves pressure on the spinal cord or nerve roots, while spinal fusion joins two or more vertebrae. Cervical laminoplasty increases space for the spinal cord and nerves in patients with symptomatic, progressive cervical stenosis and myelopathy.

Key Terms

Disc

StructureA round pad of shock-absorbing material located between the vertebrae.

Clinical changesA disc may bulge or rupture.

Potential effectA bulging or ruptured disc may press on the nerve roots.

Discography

TechniqueContrast agent is injected into a vertebral disc.

ImagingThe injection is usually followed by CT imaging.

Diagnostic purposeThe procedure evaluates the nature and extent of vertebral disc abnormality.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyBack Surgical Procedures: Cervical and Thoracic Spinal Levels - Inpatient and Outpatient Settings

Policy CodePolicy N/A

Change TypeModified

Effective DateFeb 1, 2026

Last ReviewJan 5, 2026

Next Review DateMay 8, 2023

Key ActionObtain prior authorization through eviCore before performing covered spinal surgery for Commercial members.

SourceLink

On This Page

Use ForwardHealth resources to verify payable services, provider types, specialties, places of service, and procedures reimbursable only in an inpatient hospital setting.

ForwardHealth may reduce reimbursement for office-based professional services performed in a hospital or ambulatory surgery center.

Prior Authorization

Medicare Advantage Authorization

Medicare Advantage members require prior authorization through eviCore unless the plan-specific pathway applies. Align, Align DSNP, and Great Plains members require authorization through the Health Plan.

eviCore: 888-444-6185 or www.evicore.com
Health Plan authorization: 1-800-991-8109; fax 715-221-6616
The Health Plan follows applicable Medicare guidelines; when no NCD/LCD exists, Commercial criteria apply.

Unsupported block type: prior_auth

Prior Authorization

Prior Authorization and InterQual Review

These cervical and thoracic back surgical procedures transitioned to InterQual review. Route authorization through the applicable plan pathway and use the policy’s stated criteria for procedures that are not reviewed by InterQual.

InterQual is the current medical-necessity review source for applicable procedures.
Submit through the Health Plan provider portal when the TPA pathway applies.
The policy criteria below remain applicable to procedures not reviewed by InterQual.

Step Therapy

Conservative Treatment Trial Required

A compliant conservative medical-management trial is required for all spinal surgical procedures unless an exception applies. The member must demonstrate compliance with at least two qualifying regimens for at least 6 weeks.

Qualifying regimens include interdisciplinary rehabilitation, physical therapy, an active exercise program, spinal manipulation, cognitive-behavioral therapy, and pain management with appropriately prescribed medications or injections.
The trial may be waived for spinal cord compression; cauda equina syndrome; myelopathy; severe weakness graded 4 or less on the MRC scale; severe stenosis with instability; or a progressive neurological deficit on serial examinations.

Denial Risk

Clinical Criteria Not Met

Services that do not meet the stated clinical criteria will be denied as not medically necessary. Services not listed with clinical criteria are considered experimental or investigational.

Document the applicable clinical criteria and supporting medical-necessity information with the authorization request.
Treatment without stated criteria is subject to experimental/investigational classification.

Denial Risk

Experimental Spinal Procedures

Certain spinal procedures are considered experimental and investigational and are not covered under the applicable Commercial limitations and exclusions.

Cervical and thoracic provocative discography.
Percutaneous disc decompression.
Bone marrow aspiration for bone grafting when performed for spine surgery.

Denial Risk

Thermal Intradiscal Procedures Not Covered

Thermal intradiscal procedures are unproven and not medically necessary for treating discogenic pain.

Cervical intradiscal radiofrequency lesioning.
Intradiscal biacuplasty, intervertebral disc biacuplasty, or cooled radiofrequency.
Nucleoplasty, including percutaneous radiofrequency thermomodulation or percutaneous plasma diskectomy.
PIRFT, intradiscal radiofrequency thermocoagulation, intradiscal radiofrequency thermomodulation, or percutaneous radiofrequency thermomodulation.
Radiofrequency annuloplasty.

Denial Risk

Family Health Center Setting Exclusion

Family Health Center does not cover surgical services performed in the specified facility settings because these services are available only in those settings.

No coverage for surgery performed in an inpatient setting.
No coverage for surgery performed in an outpatient surgery setting.
No coverage for surgery performed in an observation or ambulatory surgical setting.

Billing Rule

Robotic Navigation Billing Rule

Computer-assisted navigational robotic systems are no longer considered experimental or investigational effective May 1, 2021, but the service is not separately reimbursed.

Examples include Mako, OrthAlign, and BrainLab.
Do not bill the robotic navigation system as a separately reimbursed service.

Pain assessmentThe pain response to disc injection is characterized, including whether it reproduces the individual's usual pain.

Clinical objectiveReproduction of the individual's usual pain may help confirm the disc as the source of back pain.

Laminoplasty

Procedure typeA posterior cervical surgery performed through an incision at the back of the neck.

Primary purposeThe operation opens and increases space for the spinal cord and nerves.

Typical indicationIt is performed for symptomatic, progressive cervical spinal stenosis and myelopathy.

Compression patternIt is commonly performed when most spinal compression is located behind the spinal cord.

Fusion distinctionUnlike anterior cervical corpectomy and fusion, it does not involve placing a large strut graft and fusing multiple spinal levels together.

Myelopathy

DefinitionDamage or injury to the spinal cord.

Common causesCauses may include severe compression from degenerative disease, disc herniation, congenital stenosis, spinal stenosis, autoimmune disorders, or trauma.

Underlying effectThe condition can impair nerve signaling between the brain and the body.

Possible neurological effectsSymptoms may include weakness, numbness, loss of coordination, and problems with balance or bowel/bladder control.

Spinal Decompression Surgery

DefinitionA general term for various procedures intended to relieve symptoms caused by pressure or compression on the spinal cord or nerve roots.

Potential sources of compressionBulging or collapsed discs, thickened joints, loosened ligaments, and bony growths can narrow the spinal canal or spinal nerve openings.

Clinical effectNarrowing of the spinal canal or nerve openings can cause irritation of the spinal cord or nerve roots.

Spinal Fusion

DefinitionA neurosurgical or orthopedic surgical technique that joins two or more vertebrae.

Surgical purposeThe technique creates a connection between multiple vertebrae as part of spinal surgery.

Related distinctionLaminoplasty may increase space for the spinal cord and nerves without fusing multiple spinal levels together.

Spinal Stenosis

DefinitionAbnormal narrowing of the spinal canal.

LocationSpinal stenosis may occur in any region of the spine.

Neurological effectThe narrowing can restrict the spinal canal and result in a neurological deficit.

Possible symptomsSymptoms may include pain, numbness, paresthesia, and loss of motor control.

Policy-Added Definition

Policy updateA definition was added to the policy in January 2026.

Available wordingThe definition text is not included in the available policy text.

Related updateThe January 2026 update also revised ForwardHealth language.