Criteria
ANTERIOR CERVICAL FUSION FOR DEGENERATIVE DISEASE
Single or multilevel anterior cervical discectomy and fusion (ACDF) is considered medically necessary for treatment of symptomatic degenerative disease when
ALL
of the following criteria are met:
- unremitting cervical radiculopathy and/or myelopathy (i.e., neck and arm pain) resulting in disability and/or neurological deficit that are refractory to at least six weeks of standard conservative, nonoperative management (e.g., reduced activities, exercise, analgesics, physical therapy), in the absence of progressive or severe myelopathy
-
complex imaging studies (i.e., CT, MRI, X-ray) demonstrate at least
ONE
of the following at each impacted level being considered for the fusion:
Herniated nucleus pulposus
Spondylosis (i.e., presence of osteophytes)
Visible loss of disc height compared to adjacent levels with resultant foraminal stenosis
- physical examination findings and imaging studies correlate with each level being considered for the fusion
CERVICAL FUSION FOR INSTABILITY
Single or multilevel cervical fusion is considered medically necessary for
ANY
of the following indications when there is an associated spinal instability:
- acute spinal fracture and/or dislocation
- neural compression after spinal fracture
- traumatic ligamentous disruption
- epidural compression, fracture or vertebral destruction from spinal tumor or cyst
- spinal tuberculosis
- spinal decompression or debridement for infection (e.g., discitis, osteomyelitis, epidural abscess)
- spinal decompression for myelopathy associated with ossification of the posterior longitudinal ligament
- spinal decompression for myelopathy associated with subluxation in rheumatoid arthritis
- cervical spinal deformity associated with neurological symptoms of myelopathy or radiculopathy (e.g., sagittal plane angulation of more than 11 degrees between adjacent segments, subluxation of greater than 3.5 mm)
- as an adjunct to cyst excision of synovial facet cysts in the cervical spine
- posttraumatic cervical instability
- atlantoaxial instability (e.g., atlas and axis fracture, nonunion)
-
treatment of cervical spine fracture/dislocation associated with acute cervical radiculopathy or
myelopathy
- multilevel spondylotic myelopathy with kyphosis, when symptoms of myelopathy are present and imaging studies correlate with symptoms and demonstrates cord compression
-
cervical instability from any ONE (1) of the following:
Klippel-Feil syndrome
Down's syndrome
Skeletal dysplasia or connective tissue disorder
CERVICAL FUSION FOR IATROGENIC INSTABILITY
Cervical fusion is considered medically necessary for intraoperative iatrogenic spinal instability of the level or levels involved resulting from
ANY
of the following surgical procedures:
- removal of 50% or more of the facets bilaterally
- removal of 75% or more of a single facet
- following cervical corpectomy*, as part of a stabilization procedure
*Note:
Corpectomy is a procedure in which at least 50% or more of the body of the vertebrae is removed.
POSTERIOR CERVICAL FUSION FOR INSTABILITY: SPINAL STENOSIS
Posterior cervical fusion is considered medically necessary for the treatment of spinal stenosis with laminectomy when
ALL
of the following criteria are met:
- symptoms of myelopathy and/or radiculopathy
- failure of at least three (3) consecutive months of physician-supervised conservative medical management including exercise, nonsteroidal and/or steroidal medication (unless contraindicated), physical therapy and activity lifestyle modification in the absence of progressive or severe myelopathy
- clinically significant functional impairment (e.g., inability to perform household chores or prolonged standing, interference with essential job functions)
-
central, lateral recess, foraminal stenosis or synovial cyst is demonstrated on imaging studies (e.g., radiographs, magnetic resonance imaging [MRI], computerized tomography [CT], myelography) that
correlates with the clinical symptoms and/or signs
-
radiographic evidence of
EITHER
of the following:
subluxation or translation of more than 3.5 mm on static lateral views or dynamic radiographs
sagittal plane angulation of more than 11 degrees between adjacent segments
CERVICAL FUSION FOLLOWING PRIOR SPINAL SURGERY: WITHOUT SPONDYLOLISTHESIS
Cervical fusion is considered medically necessary for treatment of symptomatic adjacent or same segment stenosis following prior spinal surgery in the absence of spondylolisthesis, when
ALL
of the following criteria have been met:
-
unremitting pain and significant functional impairment for at least 3 months in the absence of myelopathy that persists despite structured*, physician-supervised conservative medical management, which
includes
ALL
of the following components
exercise, including core stabilization exercises
analgesics, nonsteroidal anti-inflammatory medication, unless contraindicated
physical therapy, including passive and active treatment modalities
activity/lifestyle modification
- physical examination findings and imaging studies correlate with each level being considered for the fusion
*Note:
Structured medical management consists of medical care that is delivered through regularly scheduled appointments, including follow-up evaluation, with licensed healthcare professionals.
CERVICAL FUSION FOLLOWING PRIOR SPINAL SURGERY: PSEUDOARTHROSIS
Cervical fusion is considered medically necessary for the treatment of pseudoarthrosis (i.e., nonunion of prior fusion) of the cervical spine at the same level(s) when it has been at least 12 months from the prior
surgery and
ALL
of the following criteria are met:
- mechanical neck pain that correlates to the level of the pseudoarthrosis
- imaging studies (e.g., radiographs, CT) confirm evidence of a pseudoarthrosis (e.g., lack of bridging bone, dynamic motion on flexion-extension radiographs)
-
failure of three (3) consecutive months of physician-supervised conservative management which includes exercise, nonsteroidal and/or steroidal medications (unless contraindicated), physical therapy
and activity lifestyle modification
- the individual experienced some relief of pain symptoms following the prior spinal surgery
- the individual is a nonsmoker†, or in the absence of progressive neurological compromise the individual has refrained from use of tobacco products for at least six (6) weeks prior to the planned surgery
† Note:
Use of tobacco products have been shown to adversely affect bone healing. Smoking is associated with an increased risk of pseudoarthrosis.
CERVICAL FUSION NOT MEDICALLY NECESSARY
Cervical fusion is considered not medically necessary for the following indications:
- posterior cervical fusion with initial primary laminectomy/discectomy for nerve root decompression or spinal stenosis in the absence of spondylolisthesis or kyphosis
- anterior or posterior cervical fusion for chronic axial neck pain
- posterior cervical fusion performed with laminectomy in the absence of kyphosis (e.g., degenerative spine) or subluxation/translation of more than 3.5 mm
Isolated cervical facet fusion, including facet joint implants and/or bone graft substitutes used exclusively as stand-alone stabilization devices for treatment of facet joint pain is considered experimental, investigational or unproven.
Procedure Codes
Cervical Fusion: Anterior Procedure Codes
| 22548 | 22551 | 22552 | 22554 | 22585 | 22808 | 22810 |
| 22812 |
Cervical Fusion: Posterior Procedure Codes
| 22590 | 22595 | 22600 | 22614 | 22800 | 22802 |
The following are considered Experimental, Investigational or Unproven when used to report isolated cervical facet fusion, including facet joint implants and/or bone graft substitutes used exclusively as stand-alone stabilization devices for treatment of facet joint pain:
Procedure Codes
