ANY of the following

• 1. Acute traumatic spine injury with instability

  • Acute traumatic spine injury with evidence of instability and stabilization not achievable by closed means.
  • Any one of: (A) Vertebral fracture (including fracture of vertebral body/posterior elements and subluxation); (B) Vertebral dislocation; (C) Ligamentous disruption.

• 2. Motor deficit or severe radicular pain due to myelopathy with cord compression

  • Myelopathy with spinal cord compression confirmed by imaging and decompressive surgery expected to result in instability.
  • Any one of: (A) Weakness or severe radicular pain; (B) Bowel or bladder dysfunction; (C) Spasticity; (D) Bilateral loss of dexterity; (E) Gait disturbance.

• 3. Vertebral body destruction

  • Vertebral body destruction confirmed by imaging for which correction will cause instability.
  • Includes any one of: (A) Resolved osteomyelitis; (B) Resolved discitis/epidural abscess; (C) Tumor of spine or spinal cord.

• 4. Non‑traumatic instability, adult deformity, severe foraminal stenosis, disc disease, or nonunion WITH motor deficit

  • Motor strength at least 3/5 weakness (i.e., presence of motor deficit).
  • OR, if motor deficit is not present, see criterion 5.

• 4. Alternative pathway for criterion 4 (when using imaging/functional thresholds)

  • When motor deficit is present OR when using the alternative pathway, the following must be satisfied:
  • Interferes with activities of daily living (ADLs).
  • Any one of the following imaging/translation thresholds: (i) Translation on x-ray or MRI > 3 mm, > 15% or 22 degrees for lumbar; (ii) > 3 mm, > 20% or 11 degrees for cervical; (iii) Disc disease supported by imaging.
  • Pain continues after 6 weeks of non‑operative therapy including ALL of: (i) Analgesics; (ii) Activity modification; (iii) Physical therapy or chiropractic therapy: minimum of 12 visits within a 6‑week period; must have been performed within the previous year (recommended that at least four of these visits be performed in‑person); (iv) Evaluation for spinal injection.

• 5. Non‑traumatic instability, adult deformity, severe foraminal stenosis, disc disease, or nonunion WITHOUT motor deficit

  • No motor deficit; AND all of the following must be present:
  • Interferes with ADLs.
  • Instability supported by x‑ray with any one of: (i) Translation on x‑ray or MRI > 3 mm, > 15% or 22 degrees for lumbar; (ii) > 3 mm, > 20% or 11 degrees for cervical; (iii) Disc disease supported by imaging.
  • Pain continues for 6 months or more despite non‑operative therapy, including at least 6 weeks of ALL: (i) Analgesics; (ii) Activity modification; (iii) Physical therapy or chiropractic therapy: minimum of 12 visits within a 6‑week period; must have been performed within the previous year (recommended that at least four of these visits be performed in‑person); (iv) Evaluation for spinal injection.
  • Tobacco smoking (including cigarettes, e‑cigarette usage, vaping, or inhalation of other substances) must be discontinued ≥ 3 months prior to surgery.

• 6. Cauda equina syndrome

  • Cauda equina syndrome with motor deficit or severe radicular pain confirmed by imaging; AND any one of: (i) Bilateral lower extremity weakness or numbness or pain; (ii) Bowel or bladder dysfunction with other etiologies excluded; (iii) Diminished rectal sphincter tone on exam; (iv) Perianal or perineal 'saddle' anesthesia on exam.

• 7. Pediatric scoliosis surgery

  • Patient age ≤ 21 with progressive adolescent idiopathic scoliosis and either Cobb angle > 50 degrees or rapidly progressive curve > 40 degrees.

ALL of the following

• Dystonia indication

  • Primary (idiopathic or genetic) dystonia: age ≥ 7 years with generalized or segmental dystonia refractory to optimal medical management and botulinum toxin for focal/segmental cases when appropriate; and demonstrable functional impairment.
  • Note: Secondary dystonias (e.g., due to cerebral palsy, neurodegenerative disorders, or fixed structural lesions) are excluded per investigational/not covered list.

• Essential tremor indication

  • Medically refractory essential tremor causing significant functional impairment despite optimal medical therapy and/or intolerable medication adverse effects; DBS of the ventral intermediate nucleus (VIM) may be considered.

ANY of the following

• Obsessive‑compulsive disorder (OCD).
• Treatment of primary psychiatric disorders other than investigational protocols (e.g., depression) — considered investigational.
• Secondary dystonias (e.g., dystonia secondary to cerebral palsy, fixed structural lesions, or neurodegenerative disease).
• Other indications without established evidence of benefit such as obesity, addiction, or Tourette syndrome outside protocolized research settings.

ALL of the following

• Diagnosis of idiopathic Parkinson's disease with motor complications (motor fluctuations, dyskinesias, or medication‑refractory tremor).
• Good levodopa responsiveness demonstrated on medication challenge testing (predicts motor benefit).
• Predominant motor symptoms that are not primarily cognitive or behavioral.
• Absence of significant cognitive impairment or uncontrolled psychiatric disease; formal neuropsychological testing documentation recommended if concerns exist.
• Reasonable general medical condition to undergo surgery and follow‑up programming.

ALL of the following

• Hardware injections for the assessment of chronic back pain are considered not covered because they are investigational and lack sufficient evidence demonstrating diagnostic or therapeutic benefit beyond noninvasive assessment methods.

ALL of the following

• Device is FDA‑approved for the indicated use.
• Device is not the StaXx XD implant (StaXx XD is excluded/not covered).

ALL of the following

• Migraine headache surgery, including procedures targeting peripheral trigger sites or decompression/neuroplasty for migraine, is considered not covered due to insufficient evidence for long‑term efficacy and safety.
• General evidence summary: Available studies are limited by small sample sizes, heterogeneity of procedures, and limited high‑quality randomized controlled trial data — therefore clinical benefit is unproven.

ANY of the following

• ApiFix device for progressive adolescent idiopathic scoliosis — considered not covered/experimental due to insufficient evidence of long‑term outcomes and comparative effectiveness.
• Vertebral body tethering (VBT) devices for progressive adolescent idiopathic scoliosis — considered not covered/experimental outside of specified research protocols due to uncertain long‑term effectiveness and complication profile.

ANY of the following

• PNS for occipital neuralgia and chronic headaches is considered not covered/ investigational when evidence does not demonstrate consistent durable benefit beyond conservative therapies and established neuromodulation approaches.

ALL of the following

• QEEG (brain mapping) is considered not covered for routine diagnostic use due to insufficient evidence that it improves diagnostic accuracy or clinical outcomes beyond standard EEG interpretation.

ALL of the following

• Patient age ≥ 18 years.
• Diagnosis of medically refractory focal epilepsy with disabling partial (focal) seizures despite adequate trials of appropriate anti‑seizure medications.
• Seizure focus (or up to two foci) well localized to a cortical region(s) not amenable to resection or patient is not a candidate for resective surgery; localization documented by concordant multimodal testing (video‑EEG, MRI, PET/SPECT as applicable).
• Adequate trial of and failure of at least two appropriate anti‑seizure medications (either as monotherapy or in combination) unless contraindicated or not tolerated.

ALL of the following

• RNS implantation and device programming should follow applicable CPT/HCPCS coding and documentation requirements; prior authorization may be required per payer rules.
• Covered programming visits related to RNS (initial programming, adjustments) are billable when medically necessary and documented; device‑related supplies and lead/devices billed using applicable HCPCS codes must match the device implanted.
• Ensure documentation supports medical necessity for each programming visit and for any replacement or revision procedures; apply applicable implantable device and supply coding guidance.

ALL of the following

• SPG injections for the management of headaches are considered not covered/ investigational due to insufficient evidence of durable clinical benefit.

ALL of the following

• For Select Health Medicare (CMS) and Select Health Community Care (Medicaid), coverage determinations for SPG injections follow applicable CMS or state Medicaid policy. If CMS or state determinations exist, those take precedence over Commercial policy; absent those determinations, the Select Health Commercial policy may be applied.

ALL of the following

• Diagnosis of histologically confirmed glioblastoma multiforme (GBM) consistent with FDA‑cleared indication for the device.
• Patient age > 22 years (per device labeling).
• Treatment is for newly diagnosed or recurrent GBM as specified by the FDA indication and device labeling; patient is receiving concomitant chemotherapy if indicated by labeling (e.g., temozolomide for newly diagnosed GBM).
• Device provided and used per manufacturer and FDA labeling; exclusions include use outside FDA‑cleared indications which is not covered.

ALL of the following

• Initial authorization duration follows plan policy (typical initial authorization period consistent with clinical benefit assessment).
• Reauthorization requires documented clinical benefit and device adherence; documentation must include device usage logs meeting wear‑time thresholds (per device guidance) and clinical status reporting.
• Device rental/coverage limits and reauthorization criteria follow manufacturer guidance and payer policy; use outside FDA‑cleared indications is not authorized.

ALL of the following

• Coverage is determined by the Centers for Medicare and Medicaid Services (CMS). If a CMS national or local coverage determination exists, that determination supersedes Select Health Commercial policy for Medicare members.
• If no CMS determination exists and InterQual criteria are not available, Select Health Commercial policy applies to Medicare cases as noted in the policy.

ALL of the following

• Select Health Community Care policies typically align with State of Utah Medicaid policy, including use of InterQual where specified. State determinations and Medicaid guidance take precedence for Medicaid members; absent state guidance, Select Health Commercial policy may be applied.