OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

ModifieduniverahealthcarePolicy 07.01.117

Lumbar Fusion (arthrodesis) with decompression

Customize your policy alerts

Sign up for univerahealthcare Policy 07.01.117 alerts

Get alerted when Policy 07.01.117 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines medical necessity criteria for lumbar fusion with direct or indirect decompression in adult patients, including imaging and perioperative requirements for instability and anticipated iatrogenic instability.

Policy Summary

Payeruniverahealthcare

PolicyLumbar Fusion (arthrodesis) with decompression

Policy CodePolicy 07.01.117

Change TypeUpdated nicotine-free documentationadjusted PI-LL numeric valuemerged prior policies and added pediatric criteria

Effective DateOct 15, 2026

Last ReviewOct 15, 2025

Next Review DateJun 1, 2027

Key ActionPrior authorization must document clinical candidacy for lumbar decompression and required imaging, conservative therapy history, and nicotine-free status (or objective cotinine testing).

SourceLink

POLICY UPDATE CHANGES

Annual review; updated criteria for documentation of nicotine-free status.

Off-cycle review; update to the value for pelvic incidence-lumbar lordosis (PI-).

Policy merged (previously 7.01.90 & 7.01.83) and retitled to 'Lumbar Fusion'; redundant criteria removed and pediatric lumbar fusion criteria added.

Headings added throughout policy statements section.

6 weeksnicotine abstinence period (validated)

3 mmdynamic instability translational threshold

3 monthsminimum failed conservative care

Cobb >50°adolescent scoliosis fusion threshold

<=10 ng/mlserum cotinine non-smoking cutoff

7not medically necessary sole indications listed

Coverage Criteria for Lumbar Fusion

Actual Instability

Covered when ALL of the following are met for Actual Instability:

Candidate for decompression: The individual is a candidate for lumbar decompression (refer to Corporate Medical Policy #7.01.113 Lumbar Decompression)

Imaging shows one of the specified instability findings: Imaging shows any of: degenerative spondylolisthesis without spondylolysis with EITHER dynamic segmental instability on flexion-extension plain x-rays or supine/upright comparison with translational difference > 3 mm OR Meyerding Grade II or higher; OR spondylolisthesis with spondylolysis with multi-level spondylolysis on plain x-rays; OR Meyerding Grade I–II with progression on plain x-rays; OR Meyerding Grade III+ with ≥50% anterior slippage or progression on plain x-rays; OR postoperative instability from facet excision exceeding 50% bilaterally or ≥75% of a single facet; OR pars fracture; OR previous lumbar decompression resulting in iatrogenic spondylolisthesis (note: if instability is created or identified intra-operatively, pre-op imaging criteria are not required)

Nicotine-free status: Documentation of nicotine-free status including EITHER: individual is a never smoker; OR abstained from smoking, smokeless tobacco, or nicotine replacement therapy for at least six (6) weeks prior to planned surgery validated by objective cotinine testing (serum, urine, or saliva) with results within the normal range for the testing method and lab

Policy Summary

Payeruniverahealthcare

PolicyLumbar Fusion (arthrodesis) with decompression

Policy CodePolicy 07.01.117

Change TypeUpdated nicotine-free documentationadjusted PI-LL numeric valuemerged prior policies and added pediatric criteria

Effective DateOct 15, 2026

Last ReviewOct 15, 2025

Next Review DateJun 1, 2027

Key ActionPrior authorization must document clinical candidacy for lumbar decompression and required imaging, conservative therapy history, and nicotine-free status (or objective cotinine testing).

SourceLink

On This Page

Anticipated Iatrogenic Instability

Covered when ALL of the following are met for Anticipated Iatrogenic Instability:

Candidate for decompression or corpectomy: The individual is a candidate for lumbar decompression or lumbar corpectomy (refer to Corporate Medical Policy #7.01.113 Lumbar Decompression)

Anticipated mechanisms creating instability: Anticipated iatrogenic instability expected from planned surgical disruption such as: facet joint excision exceeding 50% bilaterally or ≥75% of a single facet; removal of the pars interarticularis requiring fusion; decompression for Meyerding Grade I or higher spondylolisthesis with foraminal stenosis; or complete/partial corpectomy (removal of ≥1/3 of the vertebral body)

Corpectomy for osteophyte resection alone is insufficient (requires ≥1/3 vertebral body removal)

Nicotine-free documentation: Documentation of nicotine-free status via either never smoker OR objective cotinine testing demonstrating ≥6 weeks abstinence prior to planned surgery6 weeks and cotinine testing

Anticipated Iatrogenic Instability

Anticipated Iatrogenic Instability — Covered when ALL of the following are met

Base candidacy: Individual is a candidate for lumbar decompression or lumbar corpectomy (refer to Corporate Medical Policy #7.01.113 Lumbar Decompression)

Mechanisms creating anticipated instability: Anticipated iatrogenic instability created by at least one of: facet joint excision exceeding 50% bilaterally or ≥75% of a single facet; removal of the pars interarticularis requiring fusion; decompression for Meyerding Grade I or higher spondylolisthesis with foraminal stenosis; or complete/partial corpectomy (removal of ≥1/3 of vertebral body)

Corpectomy for osteophyte resection alone does not meet extent

Nicotine-free documentation: Documentation of nicotine-free status via never smoker OR objective cotinine testing showing ≥6 weeks abstinence prior to planned surgery6 weeks and cotinine testing

Adult Degenerative Spinal Deformity

Adult Degenerative Spinal Deformity — Covered when ALL of the following are met

Base candidacy: Individual is a candidate for lumbar decompression or lumbar corpectomy (refer to Corporate Medical Policy #7.01.113 Lumbar Decompression)

Imaging findings: Imaging shows either coronal plane deformity (any of: Cobb angle > 30°; asymmetric disc collapse causing symptomatic foraminal narrowing; global coronal imbalance causing head/trunk shift off midline) OR sagittal imbalance (sagittal vertebral axis > 8 cm OR pelvic incidence–lumbar lordosis mismatch > 15°)Cobb >30°; SVA >8 cm; PI-LL >15°

Failed conservative management: Less than clinically meaningful improvement after BOTH prescription-strength analgesics/steroids/gabapentinoids/NSAIDs AND a provider-directed exercise program for at least three (3) consecutive months unless contraindicated>= 3 months

Behavioral health: Absence of untreated, underlying mental or behavioral health disorders (e.g., depression, chronic pain syndrome, secondary gain, opioid or alcohol use disorders)

Nicotine-free documentation: Document nicotine-free status via either never smoker OR abstinence from tobacco/nicotine for at least six (6) weeks prior to planned surgery validated by objective cotinine testing (serum, urine, or saliva)6 weeks and cotinine testing

Initial Disc Herniation

Initial Disc Herniation — Covered when ALL of the following are met

Initial discectomy candidacy: The individual is a candidate for an initial primary discectomy (refer to Corporate Medical Policy #7.01.98 Lumbar Microdiscectomy)

Advanced imaging shows any of: Advanced imaging shows ANY of the following: primary extraforaminal L5-S1 herniation not amenable to far‑lateral approach because of iliac wings; primary foraminal herniation requiring facet restriction to retrieve the disc that would result in iatrogenic instability; OR primary disc herniation at the level of the spinal cord (low‑lying conus medullaris)

Nicotine-free documentation: Documentation of nicotine-free status including EITHER: individual is a never smoker; OR abstained from smoking, smokeless tobacco, or nicotine replacement therapy for at least six (6) weeks prior to planned surgery validated by objective cotinine testing6 weeks abstinence with normal cotinine test

Recurrent Disc Herniation

Recurrent Disc Herniation — Covered when ALL of the following are met

Repeat discectomy candidacy: The individual is a candidate for repeat lumbar discectomy (refer to Corporate Medical Policy #7.01.98 Lumbar Microdiscectomy)

Imaging evidence of anterolisthesis resulting in either: Imaging shows evidence of anterolisthesis at the requested level(s) that results in EITHER dynamic segmental instability on flexion–extension or supine/upright comparison with translational difference > 3 mm between views OR Meyerding Grade II or higher spondylolisthesis> 3 mm or Meyerding Grade II+

Nicotine-free documentation for recurrent herniation: Documentation of nicotine-free status as either a never smoker OR at least six (6) weeks abstinence validated by objective cotinine testing6 weeks

Degenerative spondylolisthesis without spondylolysis

Covered when ALL of the following are met

Imaging criteria: Imaging at the requested level(s) shows EITHER dynamic segmental instability (>3 mm translational difference) on flexion–extension/plain x‑rays or supine/upright comparison OR Meyerding Grade II or higher spondylolisthesis

Symptom requirement: Subjective symptoms include significant daily pain causing clinically significant functional impairment (e.g., inability to perform household chores, prolonged standing)

Conservative management: Less than clinically meaningful improvement with BOTH prescription‑strength analgesics/steroids/gabapentinoids/NSAIDs AND a provider‑directed exercise program for at least three (3) consecutive months unless contraindicated>= 3 months

Behavioral health: Absence of untreated underlying mental or behavioral health disorders (e.g., depression, chronic pain syndrome, secondary gain, opioid or alcohol use disorders)

Nicotine status: Documentation of nicotine‑free status: either never smoker OR abstinent for at least six (6) weeks prior to planned surgery validated by objective cotinine testing (serum, urine, or saliva)>= 6 weeks for abstinent patients

cotinine testing methods: serum, urinary, or saliva; values within normal range for lab

Spondylolisthesis with spondylolysis (Isthmic)

Covered when ALL of the following are met

Imaging criteria: Imaging at the requested level(s) shows ANY of: Meyerding Grade I–II with plain x‑rays supporting progression of anterolisthesis; OR Meyerding Grade III+ with ≥50% anterior slippage or progression on plain x‑rays; OR progressive spinal pain without confirmatory imaging of progression; OR multi‑level spondylolysis on plain x‑rays

Symptom requirement: Subjective symptoms include significant daily pain causing clinically significant functional impairment (e.g., inability to perform household chores, prolonged standing)

Spondylolisthesis with Spondylolysis

Spondylolisthesis with spondylolysis (isthmic spondylolisthesis) — Covered when ALL the following are met

Conservative pharmacologic and exercise therapy: Less than clinically meaningful improvement with BOTH for at least three (3) consecutive months (unless contraindicated): (1) prescription‑strength analgesics, steroids, gabapentinoids or NSAIDs; AND (2) provider‑directed exercise program prescribed by PT, chiropractic, osteopathic or allopathic physician3 months

Behavioral health: Absence of untreated underlying mental or behavioral health disorders (e.g., depression, chronic pain syndrome, secondary gain, opioid or alcohol use disorders)

Nicotine status: Documentation of nicotine‑free status including EITHER: never smoker OR refrained from smoking, smokeless tobacco, or nicotine replacement therapy for at least six (6) weeks prior to planned surgery validated by objective cotinine testing (serum, urine, or saliva)6 weeks abstinence with cotinine test

Objective cotinine testing methods verified within normal lab range.

Discogenic Lower Back Pain / Degenerative Disc Disease

Discogenic lower back pain / degenerative disc disease — Covered when ALL the following are met

Imaging: Plain x‑rays and advanced imaging (CT or MRI) at the requested level(s) show moderate to severe single‑level disc degenerationsingle‑level moderate‑severe degeneration

Duration of symptoms: Chronic, unremitting, discogenic axial low back pain and associated disability secondary to single‑level DDD for at least one (1) year≥1 year

Functional impact: Subjective symptoms include significant daily pain causing clinically significant functional impairment (e.g., inability to perform household chores, prolonged standing)daily significant pain

Structured nonoperative management: Structured physician‑supervised, multi‑modal nonoperative management with licensed providers including regularly scheduled appointments and follow‑up evaluation; less than clinically meaningful improvement after specified nonoperative treatments

Required nonoperative trials: Less than clinically meaningful improvement with: provider‑directed exercise program for at least twelve (12) months AND prescription‑strength analgesics/steroids/gabapentinoids/NSAIDs for at least twelve (12) consecutive months; OR epidural steroid/selective nerve root block at the same level(s); OR facet joint injection/medial branch block/radiofrequency ablation12 months for meds/exercise or appropriate injections

Behavioral health: Absence of untreated underlying mental or behavioral health disorders (e.g., depression, chronic pain syndrome, secondary gain, opioid or alcohol use disorders)

Adult Degenerative Spinal Deformity

Adult Degenerative Spinal Deformity — Covered when ALL the following are met:

Imaging findings

Coronal plane deformity: Any of: Cobb angle > 30°; asymmetric disc collapse causing symptomatic foraminal narrowing; coronal imbalance with head/trunk shift off midlineCobb >30°
Sagittal imbalance: Any of: sagittal vertebral axis > 8 cm; pelvic incidence–lumbar lordosis mismatch > 15°SVA >8 cm or PI‑LL >15°

Conservative management failure: Less than clinically meaningful improvement with BOTH prescription‑strength analgesics/steroids/gabapentinoids/NSAIDs AND a provider‑directed exercise program for at least three (3) consecutive months unless contraindicated>= 3 months

Behavioral health: Absence of untreated underlying mental or behavioral health disorders (e.g., depression, chronic pain syndrome, secondary gain, opioid or alcohol use disorders)

Nicotine‑free documentation: Documentation of nicotine‑free status via either never smoker OR refrained from tobacco/nicotine for at least six (6) weeks prior to planned surgery validated by objective cotinine testing (serum, urine, or saliva)6 weeks with cotinine test

Symptomatic Pseudoarthrosis

Repeat lumbar fusion for symptomatic pseudoarthrosis is considered medically necessary when ALL of the following are met:

Timing: Greater than six (6) months since the prior lumbar fusion> 6 months

Symptoms: Subjective symptoms include significant daily pain defined as clinically significant functional impairment (e.g., inability to perform household chores, prolonged standing)clinical significance

Physical exam: Post‑operative physical exam findings are concordant with the individual's symptomsconcordant exam

Conservative care: Less than clinically meaningful improvement after six (6) weeks of non‑surgical treatment with BOTH prescription‑strength analgesics/steroids/gabapentinoids/NSAIDs AND a provider‑directed exercise program>= 6 weeks

Imaging evidence: Post‑operative imaging (performed at no less than six (6) months after the prior lumbar fusion) shows pseudoarthrosis at the requested level(s)imaging >= 6 months post‑op

MRI/CT concordance: Post‑operative MRI/CT findings are concordant with the individual's symptomsconcordant imaging

Behavioral health: Absence of unmanaged significant mental or behavioral health issues (e.g., major depressive disorder, chronic pain syndrome, secondary gain, opioid or alcohol use disorders)managed or absent

Nicotine status: Documentation of nicotine‑free status either as never smoker OR abstinent for at least six (6) weeks prior to planned surgery validated by objective cotinine testing>= 6 weeks abstinent with cotinine test normal

Lumbar fusion — Post-disc arthroplasty indications

Lumbar fusion following failed disc arthroplasty

Indications: Lumbar fusion (with or without decompression) following failed lumbar disc arthroplasty is medically necessary when performed for EITHER of the specified indications in policy

Failed implant: Post‑operative imaging shows evidence of lumbar disc arthroplasty implant malposition or failure (e.g., subsidence, loosening, infection, dislocation/subluxation, vertebral body fracture, dislodgement)

Neural compression indication: Evidence of neural structure compression where ALL are met: > 6 months since prior disc arthroplasty; meets criteria for lumbar fusion with or without decompression; and post‑operative MRI/CT shows neural structure compression (e.g., retained disc material or recurrent disc herniation)> 6 months

Posterior column osteotomy (SPO) medical necessity criteria

Posterior column osteotomy (SPO) is considered medically necessary when ALL of the following are met:

Primary indication: Correction of non‑fixed deformity requiring 5°–10° correction per segment for EITHER lumbar sagittal plane deformity with SVA > 8 cm or PI‑LL > 15°; OR larger coronal deformities with limited flexibility and Cobb > 30°

Osteotomy limits: Posterior column osteotomy is limited to a maximum of four (4) PCOs performed in the apex of the deformity per correction surgery (exception: no limit for Scheuermann's Kyphosis)max 4

Concurrent criteria: ALL criteria for lumbar fusion have been met per applicable procedure policy criteria (includes pediatric deformity, fusion with/without decompression, adjacent segment disease, fusion following failed disc arthroplasty, repeat fusion)

Not medically necessary - sole indications

Lumbar spinal fusion is considered not medically necessary when performed for any of the following sole indications:

Sole indications not medically necessary: Multi‑level degenerative disc disease without instability

Sole indications not medically necessary: Neuro‑compressive pathology

Sole indications not medically necessary: Facet joint disorders without instability

Sole indications not medically necessary: Initial discectomy/laminectomy without instability

Sole indications not medically necessary: Spondylolysis without spondylolisthesis

Sole indications not medically necessary: As an adjunct to primary decompression of central or lateral recess stenosis in the absence of instability, spondylolisthesis, or an actual/anticipated bony resection that will result in iatrogenic instability

Investigational devices/procedures

The following devices/procedures are considered investigational under circumstances that include, but are not limited to, the following:

Investigational devices/procedures: Device/implant not FDA approved

Investigational devices/procedures: Dynamic (intervertebral) stabilization devices (e.g., Dynesys, Stabilimax NZ)

Investigational devices/procedures: Personalized anterior or lateral body interbody cage (e.g., Aprevo 3‑D printed cage)

Investigational devices/procedures: Interspinous and interlaminar distraction devices

Investigational devices/procedures: Isolated facet fusion (stand‑alone) including certain allograft substitutes

Investigational devices/procedures: Total facet arthroplasty

Investigational devices/procedures: Pre‑sacral interbody fusion including AxiaLIF

Investigational devices/procedures: Percutaneous minimally invasive (endoscopic) lumbar fusion

Investigational devices/procedures: Laparoscopic anterior lumbar interbody fusion (LALIF)

Investigational devices/procedures: Interlaminar lumbar instrumented fusion (ILIF)

Investigational devices/procedures: Interspinous fixation/posterior non‑pedicle supplemental fixation devices (e.g., Affix, Aspen)

Investigational devices/procedures: Least invasive lumbar decompression interbody fusion (LINDIF)

Technique and device evidence statements

Device and approach evaluations (evidence statements):

Dynamic stabilization devices: Insufficient research to show improved health outcomes; not recommended by clinical guidelines

Personalized 3‑D cages: Insufficient research demonstrating equivalence or superiority to conventional cages; not supported

Minimally invasive LIF: Mid‑term outcomes comparable to open approaches after learning curve; intra‑operative outcomes (blood loss, LOS) often improved

Requires training; evidence from nonrandomized studies

DLIF/XLIF evidence: DLIF/XLIF show comparable outcomes; approach‑related transient neurologic symptoms and other complications reported in small series

Laparoscopic ALIF: Literature does not permit strong conclusions vs open fusion; potentially higher complication and conversion rates

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior authorization: document decompression candidacy and required supporting materials

Prior authorization must document that the individual is a candidate for lumbar decompression per Corporate Medical Policy #7.01.113 and include all required supporting information listed in the policy (e.g., imaging, non-surgical treatment history, nicotine-free documentation).

Confirm candidacy for lumbar decompression (refer to Policy #7.01.113).
Include CPT/ICD-10 codes and disc levels, independent radiologist reports of recent advanced imaging, flexion-extension x‑rays when indicated, and detailed nonsurgical treatment history.
Provide documentation of nicotine-free status (never smoker or objective cotinine testing) unless urgent/emergent.

Prior Authorization

Prior authorization required when fusion is planned with decompression/corpectomy/discectomy

Obtain prior authorization when lumbar fusion is being considered as part of treatment for candidates of lumbar decompression, lumbar corpectomy, or discectomy; the request must reference the applicable decompression/discectomy policy.

If fusion is planned with decompression or corpectomy, include documentation showing the individual is a candidate for the referenced procedure (Policy #7.01.113).
If fusion is being considered after planned discectomy, establish discectomy candidacy per Policy #7.01.98.

Prior Authorization

Document discectomy candidacy before considering fusion

Prior authorization requests that consider fusion following a discectomy must document that the patient meets candidacy for initial or repeat lumbar discectomy per Corporate Medical Policy #7.01.98 before fusion is pursued.

Include documentation showing the patient is a candidate for initial primary discectomy or repeat discectomy according to Policy #7.01.98.

Prior Authorization

Prior authorization: required imaging, conservative care, and status documentation

Prior authorization requires imaging evidence of instability (dynamic translation >3 mm or appropriate Meyerding grade/progression) and submission of documentation of failed conservative care and nicotine/behavioral health status as specified in the policy.

Provide flexion‑extension or supine/upright images showing translational difference >3 mm when applicable.
Provide plain x‑rays documenting Meyerding Grade II+ or progression where required.
Include documentation of failed conservative therapy and nicotine-free status per policy thresholds.

Prior Authorization

Prior authorization: document failed conservative care and provide imaging

Prior authorization must document failed conservative therapies for required durations (e.g., ≥3 consecutive months for spondylolisthesis indications; ≥12 months for discogenic DDD) and include supportive imaging per the applicable criteria.

For spondylolisthesis indications: at least three (3) consecutive months of both prescription-strength analgesics (or steroids/gabapentinoids/NSAIDs) and a provider-directed exercise program.
For discogenic DDD: structured physician-supervised multimodal nonoperative care with at least twelve (12) months of provider-directed exercise and prescription therapies, or appropriate injections.

Prior Authorization

Prior authorization for adult degenerative spinal deformity: conservative care and imaging required

For adult degenerative spinal deformity, prior authorization must confirm failed conservative management for at least three consecutive months and include imaging demonstrating coronal or sagittal deformity/imbalance per policy thresholds.

Include documentation of ≥3 months of failed prescription therapies AND provider-directed exercise.
Provide imaging demonstrating either Cobb >30° or sagittal imbalance (SVA >8 cm or PI‑LL >15°) as applicable.

Prior Authorization

Prior authorization: confirm minimum intervals and supporting documentation for repeat/adjacent-level surgery

Prior authorization must confirm minimum intervals for repeat or adjacent-level surgeries (typically ≥6 months since prior fusion or disc arthroplasty) and include supporting symptoms, exam, imaging, and nonsurgical treatment documentation.

Document time since prior fusion/disc arthroplasty (≥6 months where specified).
Provide post-operative imaging and clinical concordance demonstrating need for revision or adjacent-level fusion.

Prior Authorization

Authorization for fusion following prior fusion or disc arthroplasty: document prior surgery and failure evidence

When fusion is requested following prior fusion or disc arthroplasty, prior authorization must include documentation of the timing of the prior surgery and post‑operative imaging that demonstrates implant malposition/failure or neural structure compression when applicable.

Provide operative date(s) for prior fusion or disc arthroplasty and imaging demonstrating implant failure (e.g., subsidence, loosening) or MRI/CT evidence of neural compression.
Ensure timing requirements (e.g., >6 months for pseudoarthrosis) are met and documented.

Prior Authorization

Prior authorization required for three-column osteotomy when policy criteria met

Prior authorization is required for three-column osteotomy (PSO or VCR) when ALL listed deformity and concurrent lumbar fusion criteria are met; include the same lumbar fusion documentation required by the policy.

Demonstrate indication (e.g., fixed sagittal deformity requiring >30° correction or large fixed coronal deformity >60°).
Confirm that all lumbar fusion criteria have been met and include required documentation.

Prior Authorization

Investigational devices/procedures: identify in prior authorization

Identify use of devices or procedures listed as investigational (for example dynamic stabilization systems, personalized 3‑D printed cages, interspinous devices, AxiaLIF, endoscopic fusion) in the prior authorization; such uses may require authorization review or be denied per policy.

If an investigational device/procedure is planned, explicitly state device name and regulatory status in the submission.
Be aware that investigational uses may be considered not medically necessary or investigational per the policy.

Prior Authorization

Prior authorization: include codes, imaging, nonsurgical history, and nicotine documentation

Prior authorization requests must include procedure and diagnosis codes, imaging reports, a detailed non-surgical treatment history (type/duration/frequency/response), and nicotine-free documentation as specified in the policy.

Provide CPT and ICD-10 codes with disc levels or motion segments.
Submit independent radiologist reports of recent advanced imaging and, when indicated, flexion‑extension x‑rays.
Include documentation of nicotine-free status (never smoker or cotinine testing) unless urgent/emergent.

Prior Authorization

Authorization requirements: urgent/emergent screening and imaging

Evaluation for spine surgery prior to authorization must include screening for urgent/emergent indications; when present, urgent/emergent conditions warrant definitive surgical treatment and standard preauthorization requirements (e.g., smoking cessation proof) may be waived.

Screen for urgent/emergent conditions that would exempt standard nonsurgical and nicotine requirements.
If urgent/emergent, document the indication and imaging supporting the need for definitive surgical treatment.

Note

Prior authorization: technique-specific code requirements not detailed in excerpt—submit full operative plan

Some procedural details (e.g., specific code‑level prior authorization for laparoscopic ALIF) are discussed in the evidence/technique sections but explicit prior authorization code‑level rules are not specified in that excerpt—providers should submit full coding and operative plans as required elsewhere in the policy.

Include full procedure codes and operative plan even when technique‑specific prior authorization details are not listed in the excerpt.

Prior Authorization

Prior authorization for lumbar fusion and instrumentation: submit codes and supporting documentation

Prior authorization is required for lumbar fusion procedures and related instrumentation codes listed in the coding section; providers must submit the procedure and diagnosis codes to support medical necessity.

Include the applicable CPT codes for fusion and instrumentation and supporting ICD‑10 diagnosis codes with levels.
Ensure codes match the operative plan and imaging/clinical documentation.

Prior Authorization

Prior authorization applicability: confirm product coverage

Confirm whether the member's product covers the requested service before submitting a prior authorization request; medical policy criteria apply only when the product covers the service and services are contract dependent.

Verify product coverage (commercial, Medicaid, Medicare) and follow product‑specific rules.
If the product does not cover the service, medical policy criteria do not apply.

Prior Authorization

Discectomy‑first consideration: document discectomy candidacy per Policy #7.01.98

Providers must establish that the patient is a candidate for initial or repeat lumbar discectomy per Corporate Medical Policy #7.01.98 before fusion is considered; include that documentation in the authorization request.

Attach records demonstrating candidacy for initial or repeat discectomy per Policy #7.01.98.
Do not advance fusion prior to documenting discectomy candidacy when that is the expected pathway.

Step Therapy

Conservative management requirement: document failed medications and provider‑directed exercise

Patients must have attempted and failed both prescription‑strength medications (or steroids/gabapentinoids/NSAIDs) AND a provider‑directed exercise program for the specified duration (usually ≥3 months) unless contraindicated; document these trials in prior authorization.

For spondylolisthesis and many indications: document ≥3 consecutive months of both medication therapies and provider‑directed exercise.
If contraindications exist, provide clear documentation explaining why trials were not appropriate.

Step Therapy

Require trials of medications, exercise, and indicated injections prior to fusion

Prior authorization requires documentation of prior trials of pharmacologic therapies and a provider‑directed exercise program; for discogenic pain, also document epidural steroid or facet interventions when applicable.

For discogenic DDD: document structured physician‑supervised nonoperative care and specified injections or interventions as listed.
Provide dates, durations, and responses to each nonoperative modality.

Step Therapy

Conservative therapy requirement: document ≥3 months of failed meds and exercise

Require documentation of at least three (3) consecutive months of less than clinically meaningful improvement with BOTH prescription analgesics/steroids/gabapentinoids/NSAIDs AND a provider‑directed exercise program prior to approval unless contraindicated.

Document the type, dose, duration, and clinical response to pharmacologic therapy and the supervised exercise program.

Step Therapy

Non‑surgical therapy requirement for pseudoarthrosis: document ≥6 weeks of treatment

For symptomatic pseudoarthrosis repeat fusion requests, require at least six (6) weeks of non‑surgical treatment including prescription‑strength analgesics and a provider‑directed exercise program unless contraindicated; document this in the authorization.

Include details of the six‑week non‑surgical treatment trial and response prior to revision fusion consideration.

Documentation Required

Non‑surgical management documentation: include type, duration, frequency, and response

Document provider‑directed nonsurgical management (type, duration, frequency, and response) such as interventional pain management, medication management, chiropractic care, physical therapy or supervised active exercise as part of the prior authorization.

Provide detailed records of each nonsurgical modality and objective measures of response or reason for contraindication.

Step Therapy

Conservative therapy before fusion: document trials or document contraindications

Conservative management (rest, exercise, analgesics, injections, bracing, PT, chiropractic care) is generally required prior to fusion except when progressive neurological deficits, unstable fracture/dislocation, or progressive deformity are present; document any exceptions.

If conservative therapy is not attempted due to contraindication (e.g., progressive deficit), explicitly document the clinical rationale and supporting imaging.

Documentation Required

Required clinical and imaging documentation to support fusion criteria

Documentation must include clinical candidacy for lumbar decompression (refer to Policy #7.01.113) and imaging evidence specified by the policy (e.g., dynamic instability >3 mm, Meyerding grading, facet excision thresholds) to support fusion.

Provide flexion‑extension/x‑ray or supine/upright comparisons specifying translational millimeters or Meyerding grade.
If instability is identified intra‑operatively, note the intra‑operative exception per policy.

Documentation Required

Document nicotine‑free status: never smoker or objective cotinine testing (≥6 weeks abstinent)

Document nicotine‑free status by either a record that the individual is a never smoker or objective cotinine testing (serum, urine, or saliva) demonstrating at least six (6) weeks abstinence prior to planned surgery; include the laboratory result and testing method.

Acceptable documentation: 'never smoker' record OR cotinine test (serum/urine/saliva) with results within normal lab range validating ≥6 weeks abstinence.
When cotinine testing is used, include test date, specimen type, and numeric result (e.g., <10 ng/mL where specified).

Documentation Required

Provide cotinine test result details when used to document nicotine‑free status

Objective cotinine testing (serum, urinary, or saliva) results within the normal range for the testing method and lab must be provided to validate nicotine‑free status when abstinence is claimed.

Include the numeric cotinine value and the laboratory reference range or statement that result is within normal range.
Policy notes serum cotinine <10 ng/mL as an example threshold for non‑smoking in related sections.

Documentation Required

Imaging documentation: provide flexion‑extension or supine/upright comparisons with measurements

Include imaging reports demonstrating dynamic segmental instability on flexion‑extension x‑rays or comparison of supine and upright images with explicit measurement of translational difference in millimeters or Meyerding grade as applicable.

Provide independent radiologist interpretations and measurements (e.g., >3 mm translational difference) when claiming dynamic instability.

Documentation Required

Imaging documentation: show >3 mm translation or Meyerding Grade II+ where required

For indications that require imaging evidence, prior authorization must include imaging demonstrating either dynamic segmental instability (>3 mm translation) or Meyerding Grade II or higher (or specified progression) at the requested levels.

When applicable, include plain x‑ray progression documentation or postoperative imaging demonstrating the required Meyerding grades.

Documentation Required

Conservative therapy documentation: show ≥3 months failed meds and supervised exercise

Document that the patient had less than clinically meaningful improvement after at least three (3) consecutive months of BOTH prescription‑strength analgesics (or steroids/gabapentinoids/NSAIDs) AND a provider‑directed exercise program unless contraindicated.

Provide treatment dates, medications, dosages, exercise program details, and outcome measures demonstrating inadequate improvement.

Documentation Required

Behavioral health documentation: show no untreated significant mental/behavioral disorders

Document absence of untreated underlying mental or behavioral health disorders (e.g., depression, chronic pain syndrome, secondary gain, opioid or alcohol use disorders) and include assessment/treatment status in the authorization.

Include behavioral health screening results and documentation that any identified disorders are being appropriately treated or managed.

Documentation Required

Nicotine documentation: record never smoker or cotinine‑validated ≥6 weeks abstinence

Document nicotine‑free status as either 'never smoker' or objective cotinine test results showing abstinence for at least six (6) weeks prior to planned surgery, validated by serum/urine/saliva testing and results within the normal lab range.

State 'never smoker' in records OR attach cotinine laboratory report with specimen type, date, and numeric result indicating ≥6 weeks abstinence.

Documentation Required

Document structured, supervised multimodal nonoperative care and lack of improvement

Document structured physician‑supervised, multi‑modal nonoperative care (regularly scheduled appointments, follow-up evaluations) and show lack of clinically meaningful improvement after the specified nonoperative modalities and durations.

Include dates of visits, supervising clinician, treatment plan, and objective measures of response to nonoperative care.

Documentation Required

Nicotine status documentation: provide cotinine testing or never‑smoker record

Document nicotine‑free status either as never smoker or abstinence for at least six (6) weeks prior to planned surgery validated by objective cotinine testing (serum, urine, or saliva) with results within the normal lab range.

Attach cotinine lab report or a clear medical record entry stating 'never smoker' when applicable.
If cotinine testing used, include specimen type, date, and numeric result (e.g., <10 ng/mL when specified).

Documentation Required

Behavioral health documentation: include assessment and treatment status

Document assessment and treatment status for underlying mental or behavioral health disorders; prior authorization must show absence of untreated disorders such as major depression, chronic pain syndrome, secondary gain, or substance use disorders.

Include behavioral health evaluations and treatment plans or a statement that disorders are absent/managed.

Documentation Required

Conservative therapy documentation: show ≥3 months failed combined therapy

Document at least three (3) consecutive months of less than clinically meaningful improvement with BOTH prescription‑strength analgesics/steroids/gabapentinoids/NSAIDs AND a provider‑directed exercise program prior to authorization for many fusion indications.

Provide precise dates, therapies, adherence, and objective measures showing inadequate improvement.

Documentation Required

Repeat fusion documentation: >6 months since prior fusion and concordant symptoms

For repeat fusion for symptomatic pseudoarthrosis, document that more than six (6) months have elapsed since the prior fusion and include subjective symptoms of significant daily pain causing functional impairment.

Include prior operative date, current symptom description demonstrating clinically significant functional impairment, and timeline showing >6 months since prior fusion.

Documentation Required

Nicotine status documentation (repeat fusion and other indications): provide cotinine or never‑smoker record

Document nicotine‑free status as either never smoker or abstinent for at least six (6) weeks prior to planned surgery validated by objective cotinine testing (serum, urine, or saliva) with results within the normal lab range.

Include cotinine lab report or clinical note documenting 'never smoker' status; if abstinence claimed, provide test date and numeric result.

Documentation Required

Post‑operative imaging: provide ≥6‑month imaging showing pseudoarthrosis and concordant MRI/CT

Provide post‑operative imaging performed at no less than six (6) months after the prior fusion showing pseudoarthrosis at the requested level(s) and ensure MRI/CT findings are concordant with symptoms for repeat fusion requests.

Attach imaging reports and images performed ≥6 months post‑op demonstrating pseudoarthrosis and any MRI/CT findings that correlate with the patient's symptoms.

Documentation Required

Clinical symptom and exam documentation for repeat fusion: show concordant pain and exam findings

Document daily significant pain causing functional impairment and include post‑operative physical exam findings that are concordant with the individual's symptoms when requesting revision fusion for pseudoarthrosis.

Provide clinical exam notes showing concordance between symptoms and physical findings.

Coding and Key Quantitative Thresholds

Covered CPT Codes / Codes listedCPT

22207	Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment; lumbar
22208	Osteotomy of spine, posterior or posterolateral approach, 3 columns, each additional vertebral
22214	Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar
22216	Osteotomy of spine, posterior or posterolateral approach, each additional vertebral segment
22224	Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar
22226	Osteotomy of spine, including discectomy, anterior approach, each additional vertebral segment
22533	Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace; lumbar
22534	Arthrodesis, lateral extracavitary technique, each additional vertebral segment; thoracic or lumbar
22558	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace; lumbar
22585	Arthrodesis, anterior interbody technique, each additional interspace

1–10 of 21

1/3

HCPCS CodesHCPCS

No codes listed

ICD-10 Diagnosis CodesICD-10

M40.35-M40.37	Flatback syndrome: thoracolumbar, lumbar or lumbosacral region (code range)
M41.05-M41.9	Scoliosis (code range)
M43.00-M43.07	Spondylolysis: thoracolumbar, lumbar or lumbosacral region (code range)
M96.0	Pseudarthrosis after fusion or arthrodesis
M96.1	Postlaminectomy syndrome, not elsewhere classified
S32.000A-S32.059S	Fracture of lumbar spine (code range)

inv-60: Dynamic instability translational threshold — > 3 mm difference between views

Threshold> 3 mm difference between views

Measurement methodFlexion-extension plain x-rays or comparison of supine and upright images

Applies toDynamic segmental instability and degenerative spondylolisthesis criteria

inv-61: Nicotine abstinence period — >= 6 weeks prior to planned surgery (validated by cotinine test)

Required abstinence period>= 6 weeks prior to planned surgery

Validation methodObjective cotinine testing (serum, urinary, or saliva) with results within normal range for the testing method and lab

Accepted documentationAlternatively, documented history of 'never smoker'

inv-62: Facet excision threshold — Excision >50% bilaterally or ≥75% of a single facet

Facet excision thresholdExcision >50% bilaterally or ≥75% of a single facet

ContextCreates postoperative or anticipated iatrogenic instability requiring fusion consideration

DocumentationOperative plan or intraoperative findings describing extent of facetectomy

inv-63: Corpectomy extent — Removal of at least one-third of the vertebral body (not for osteophyte resection alone)

Corpectomy extentRemoval of at least one-third of the vertebral body

ExclusionNot considered sufficient when performed for osteophyte resection alone

ImplicationExtent of corpectomy that anticipates need for stabilization/fusion

inv-64: Cobb angle — > 30 degrees

Cobb angle threshold> 30 degrees

Applies toCoronal plane deformity criteria for adult degenerative spinal deformity and PCO consideration

MeasurementCobb angle on coronal plane radiographs

inv-65: Sagittal vertebral axis (SVA) — > 8 cm

SVA threshold> 8 cm

ContextSagittal imbalance criterion for adult deformity and SPO consideration

MeasurementSagittal vertebral axis on standing radiographs

inv-66: Pelvic incidence–lumbar lordosis (PI-LL) — > 15 degrees

PI-LL mismatch> 15 degrees

ContextPelvic incidence–lumbar lordosis mismatch threshold for sagittal imbalance and SPO consideration

UseMeasured on standing sagittal alignment radiographs/measurements

inv-67: Translational alignment difference threshold — > 3 mm

Translational alignment difference threshold> 3 mm

Applies toDynamic segmental instability on flexion-extension or supine/upright comparisons

DocumentationRadiology report should specify translational difference in millimeters

inv-68: Spondylolisthesis grade threshold — Meyerding Grade II or higher

Spondylolisthesis grade thresholdMeyerding Grade II or higher

ClassificationGrade I: 0–25%; Grade II: 25–50%; Grade III: 50–75%; Grade IV: 75–100%; Grade V: >100%

ApplicationQualifies for degenerative spondylolisthesis criteria when imaging and symptoms align

inv-69: Translational alignment difference — > 3 mm

Translational alignment difference> 3 mm

ContextDefined translational difference used to establish dynamic segmental instability

Imaging typesFlexion-extension x-rays or supine vs upright comparison

inv-70: Nicotine abstinence duration — >= 6 weeks

Nicotine abstinence duration>= 6 weeks

ValidationObjective cotinine testing (serum/urine/saliva) with lab-normal results or documented 'never smoker' status

Denial riskLack of documented nicotine-free status may risk denial of authorization

inv-71: Failed conservative therapy duration — >= 3 consecutive months

Failed conservative therapy duration>= 3 consecutive months

Required componentsPrescription-strength analgesics/steroids/gabapentinoids/NSAIDs AND provider-directed exercise program

ExceptionsUnless contraindicated or urgent/emergent indications present

inv-72: Duration thresholds for conservative care — Spondylolisthesis: ≥3 consecutive months; Discogenic DDD: ≥12 months

Duration thresholdsSpondylolisthesis: ≥3 consecutive months; Discogenic DDD: ≥12 months

Discogenic DDD requirementProvider-directed exercise and prescription-strength medications or appropriate injections for at least 12 months

Spondylolisthesis requirementAt least 3 months of combined pharmacologic and exercise therapy unless contraindicated

inv-73: Nicotine abstinence — Abstained for ≥6 weeks prior to planned surgery, validated by serum/urine/saliva cotinine within normal range

Nicotine abstinence verificationAbstained for ≥6 weeks prior to planned surgery, validated by serum/urine/saliva cotinine within normal range

Alternate documentationDocumentation of 'never smoker' status is acceptable

Lab cutoff referencePolicy references cotinine lab cutoff < 10 ng/mL for blood in documentation section

inv-74: Nicotine-free duration — >= 6 weeks (validated by objective cotinine testing)

Nicotine-free duration (objective testing)>= 6 weeks (validated by objective cotinine testing)

Accepted testsSerum, urinary, or saliva cotinine assays with results within lab normal range

Policy actionUpdated documentation criteria emphasized in policy revisions

inv-75: Cobb angle — > 30 degrees

Cobb angle threshold> 30 degrees

UseCoronal plane deformity definition for adult degenerative spinal deformity and PCO consideration

MeasurementMeasured on coronal radiographs as Cobb angle

inv-76: Sagittal vertebral axis — > 8 cm

SVA threshold> 8 cm

ContextSagittal imbalance definition for adult deformity and SPO correction indication

Measurement methodSagittal vertical axis on standing radiographs

inv-77: Pelvic incidence–lumbar lordosis (PI-LL) — > 15 degrees

PI-LL mismatch threshold> 15 degrees

ContextUsed to define sagittal imbalance for adult degenerative deformity and SPO planning

NotePolicy notes an off-cycle update to numeric PI-LL value in revisions

inv-78: Conservative therapy duration — >= 3 months

Translational alignment difference threshold> 3 mm

ContextDefines dynamic segmental instability for multiple indications (recurrent herniation, degenerative spondylolisthesis)

Required imagingFlexion-extension x-rays or supine vs upright comparison with radiology report quantifying mm difference

inv-79: Time since prior fusion for pseudoarthrosis — > 6 months

Time since prior fusion for pseudoarthrosis> 6 months

Documentation requiredPost-operative imaging performed at no less than six months after prior fusion showing pseudoarthrosis

Symptom requirementPersistent significant daily pain with functional impairment

inv-80: Minimum interval since prior fusion — >= 6 months

Minimum interval since prior fusion>= 6 months

Applies toRepeat fusion at same level or adjacent-level fusion considerations

DocumentationImaging and clinical concordant symptoms/exam required

inv-81: Conservative treatment duration — >= 6 weeks

Conservative treatment duration before repeat fusion>= 6 weeks

Required componentsPrescription-strength analgesics/steroids/gabapentinoids/NSAIDs AND provider-directed exercise program

ExceptionUnless contraindicated or urgent/emergent indications present

inv-82: Nicotine abstinence verification — >= 6 weeks abstinent validated by cotinine testing

Nicotine abstinence verification>= 6 weeks abstinent validated by cotinine testing

Acceptable testsSerum, urine, or saliva cotinine with results within normal lab range (policy references <10 ng/mL in documentation section)

AlternateDocumented 'never smoker' status acceptable

inv-83: Minimum interval after prior lumbar fusion or disc arthroplasty — >= 6 months

Minimum interval after prior fusion or disc arthroplasty>= 6 months

Applies toAdjacent segment disease and fusion following failed disc arthroplasty where timing is specified

DocumentationPost-operative imaging and clinical correlation required when applicable

inv-84: Adolescent idiopathic scoliosis Cobb angle — > 50°

AIS surgical threshold (pediatric)> 50° Cobb angle

Applies toAdolescent idiopathic scoliosis indication for definitive fusion

DocumentationConfirmatory imaging studies required

inv-85: Sagittal deformity thresholds for SPO correction — SVA > 8 cm or PI-LL > 15°

SPO sagittal deformity thresholdsSVA > 8 cm or PI-LL > 15°

UseIndication for posterior column osteotomy (SPO) to correct non-fixed sagittal deformity

Per-segment correctionSPO yields approximately 5–10° correction per segment

inv-86: Coronal deformity threshold for SPO consideration — Cobb > 30° with limited flexibility

Coronal deformity threshold for SPOCobb > 30° with limited flexibility

ContextIndication for posterior column osteotomy when non-fixed coronal deformity with limited flexibility present

LimitPCO limited to maximum of 4 per correction surgery except Scheuermann's Kyphosis

inv-87: Sagittal vertical axis (SVA) — > 8 cm

SVA threshold> 8 cm

ContextSagittal vertical axis criterion for adult degenerative spinal deformity

MeasurementStanding lateral radiograph-based SVA measurement

inv-88: Pelvic incidence minus lumbar lordosis (PI-LL) — > 15 degrees

PI-LL threshold> 15 degrees

ContextPelvic incidence minus lumbar lordosis mismatch used to define sagittal imbalance

NotePolicy records an update to PI-LL numeric value in revisions; current excerpt lists >15°

inv-89: Cobb angle for coronal deformity (posterior column osteotomy consideration) — > 30 degrees

Cobb angle for PCO consideration> 30 degrees

ContextLarger coronal deformities with limited flexibility may warrant posterior column osteotomy

MeasurementCobb angle on coronal radiographs

inv-90: Posterior column osteotomy count per correction surgery — maximum 4 (no limit for Scheuermann's kyphosis)

PCO count limit per correction surgeryMaximum 4 (no limit for Scheuermann's kyphosis)

ExceptionNo limit when correcting Scheuermann's Kyphosis

PlacementPerformed at apex of deformity

inv-91: Sagittal correction threshold for PSO — > 30 degrees

PSO sagittal correction threshold> 30 degrees

IndicationCorrection of fixed sagittal plane deformity requiring >30° correction

Concurrent requirementAll lumbar fusion criteria must be met when performing PSO in addition to fusion

inv-92: Coronal deformity threshold for three-column osteotomy — > 60 degrees

Three-column osteotomy coronal threshold> 60 degrees

IndicationLarge, fixed coronal deformities >60° amenable to asymmetric osteotomy

Pediatric inclusionIncludes pediatric spinal deformity cases when criteria met

inv-93: Nicotine cotinine lab cutoff — < 10 ng/mL

Cotinine lab cutoff< 10 ng/mL (blood) referenced for nicotine-free documentation

Serum cotinine non-smoking referenceNon-smokers typically <=10 ng/mL; second-hand exposure often 1–10 ng/mL

Test typesSerum, urine, or saliva cotinine assays referenced in policy

inv-94: Adolescent idiopathic scoliosis curve threshold — > 50-degree curve

AIS curve urgent threshold> 50-degree curve

ContextAdolescent idiopathic scoliosis with >50° curves warrants definitive surgical treatment (urgent/emergent exceptions)

DocumentationConfirmatory advanced imaging or plain x-rays required

inv-95: Serum cotinine for non-smoking — Less than or equal to 10 ng/ml

Serum cotinine for non-smokingLess than or equal to 10 ng/ml

RationaleNon-smokers exposed to typical second-hand smoke have <1 ng/ml; active smokers almost always >10 ng/ml

ReferenceNational Biomonitoring Program / CDC and policy discussion

inv-96: None specified

ValueNone specified in excerpt

ContextPolicy notes an updated numeric PI-LL value referenced in revisions but exact updated number not present in provided excerpt

ActionRefer to full policy record for updated PI-LL numeric if needed

inv-97: Pelvic incidence-lumbar lordosis (PI-LL) — Updated numeric value referenced (see policy changes)

PI-LL update noteUpdated numeric value referenced in policy history (off-cycle review) — exact updated value not present in excerpt

ActionConfirm updated PI-LL numeric in full policy document if required for authorization decisions

Revision contextListed under policy changes: 'Update to the value for pelvic incidence-lumbar lordosis (PI-)'.

Background, Definitions, and Rationale

Lumbar fusion (arthrodesis) is performed to stabilize the spine in the presence of actual or anticipated instability, commonly as an adjunct to decompression when instability is present or expected after resection.

inv-171: Dynamic segmental instability defined — Difference in translational alignment >3 mm between views

DefinitionDifference in translational alignment >3 mm between views defines dynamic segmental instability

MeasurementFlexion-extension x-rays or comparison of supine and upright images

Applies toUsed to establish degenerative spondylolisthesis and recurrent herniation fusion criteria

inv-172: Meyerding grade criteria — Meyerding Grade II or higher qualifies for degenerative spondylolisthesis without spondylolysis; Grade I–II progression supports isthmic cases

Meyerding grade criteriaMeyerding Grade II or higher qualifies for degenerative spondylolisthesis; Grade I–II progression supports isthmic cases

Grade definitionsGrade I 0–25%, Grade II 25–50%, Grade III 50–75%, Grade IV 75–100%, Grade V >100%

ApplicationUsed in imaging-based eligibility for fusion coverage

inv-173: Postoperative iatrogenic instability — Instability produced by facet joint excision thresholds

Postoperative iatrogenic instability definitionInstability produced by facet joint excision exceeding 50% bilaterally or 75% of a single facet

Clinical implicationMay warrant fusion when postoperative instability is created

DocumentationOperative report or imaging demonstrating extent of facet excision

inv-174: Anticipated iatrogenic instability definition — Expected instability after planned surgical disruption (facet excision, pars interarticularis removal, corpectomy extent)

Anticipated iatrogenic instability definitionExpected instability after planned surgical disruption (e.g., >50% bilateral or ≥75% unilateral facet excision; removal of pars interarticularis; corpectomy ≥1/3 vertebral body)

ExamplesFacet excision >50% bilaterally; single facet ≥75%; pars removal requiring stabilization; corpectomy removing ≥1/3 of vertebral body

DocumentationPre-op surgical plan describing intended resection and need for stabilization

inv-175: Adult degenerative spinal deformity definition — Coronal and/or sagittal deformity thresholds and examples

ASD definitionCoronal deformity (Cobb >30°) and/or sagittal imbalance (SVA >8 cm or PI-LL >15°) constitute adult degenerative spinal deformity

ExamplesAsymmetric disc collapse causing foraminal narrowing; global coronal imbalance; sagittal imbalance measures

PrerequisiteCandidate for decompression or corpectomy with concordant symptoms and failed conservative care per criteria

Lumbar Fusion (arthrodesis) with decompression

Sign up for univerahealthcare Policy 07.01.117 alerts

Coverage Criteria for Lumbar Fusion

Provider Requirements, Prior Authorization, and Documentation

Coding and Key Quantitative Thresholds

Background, Definitions, and Rationale

Quick Reference: Codes and Thresholds

Policy Revision History