Spinal Fusion Surgery

Medical Coverage Policy

Original Effective Date: 11/20/2008
Revised Date: 12/01/2011
Review Date: 12/01/2011 Page: 1 of 29
Policy Number: CLPD-0477-003

Change Summary: Updated Disclaimer, Coverage Determination, Coverage Limitations, Background, Provider Claims Codes,
References

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Disclaimer Medical Alternatives

Description Provider Claims Codes
Coverage Determination Medical Terms
Background References

Disclaimer State and federal law, as well as contract language, including definitions and specific inclusions/
exclusions, take precedence over clinical policy and must be considered first in determining eligibility for
coverage. Coverage may also differ for our Medicare and/or Medicaid members based on any applicable
Centers for Medicare & Medicaid Services (CMS) coverage statements including National Coverage
Determinations (NCD), Local Medical Review Policies (LMRP), and/or Local Coverage Determinations.
See the CMS web site at http://www.cms.hhs.gov/. The member's health plan benefits, in effect on the
date services are rendered, must be used. Clinical policy is not intended to preempt the judgment of the
reviewing Medical Director or dictate to providers how to practice medicine. Providers are expected to
exercise their medical judgment in rendering the most appropriate care. Identification of selected brand
names of devices, tests, and procedures in a Medical Coverage Policy are for reference only and is not an
endorsement of any one device, test or procedure over another. Clinical technology is constantly evolving,
and we reserve the right to review and update this policy periodically. No part of this publication may be
reproduced, stored in a retrieval system, or transmitted, in any shape or form or by any means, electronic,
mechanical, photocopying, or otherwise, without permission from Humana Inc.

Description Spinal fusion (also known as spinal arthrodesis) is a surgical treatment utilized
for neck or back pain that fuses (unites) two or more vertebral bodies in the
spinal column. The most common goal of spinal fusion surgery is to restrict
spinal motion in order to relieve painful symptoms. Spinal fusion surgery is
generally utilized to treat degenerative disc disease (DDD), spondylolisthesis,
trauma resulting in spinal nerve compression, abnormal spinal curvatures
(scoliosis or kyphosis) and vertebral instability caused by infections or tumors.

Spinal fusion may be performed using a minimally invasive or open approach.

All fusion surgeries involve the placement of a bone graft between the
vertebrae. The bone graft utilized may be taken either from another bone in the
patient (autograft) or from a bone bank (allograft). Bone morphogenic proteins
(BMPs) have been developed as a substitute for natural bone grafting material;
BMP facilitates in-growth of bone to accomplish the fusion (please refer to
Bone Graft Substitutes Medical Coverage Policy).
 Spinal Fusion Surgery
Original Effective Date: 11/20/2008
Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
Page: 2 of 29

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The spine may be approached and the graft placed from either the back
(posterior approach), the front (anterior approach), or by a combination of both.
A fusion can be performed with or without the use of supplemental hardware
such as plates, screws or cages that serve as an internal splint while the bone
graft heals. However, current practice most commonly employs hardware in
addition to the grafts.

Spinal fusion surgeries may also be performed in conjunction with a

laminectomy, laminotomy, foraminectomy, foraminotomy, laminoplasty,
corpectomy, or facetectomy procedure (please refer to Spinal Decompression
Surgery Medical Coverage Policy).

Another approach to spinal fusion utilizes a laparoscope (endoscope), which is

proposed as a minimally invasive technique to decrease injury to surrounding
tissues and promote a quicker recovery time. There are several types of these
procedures/techniques, including but not limited to the axial lumbar interbody
fusion via a pre-sacral approach (AxiaLIF®), extreme lateral interbody fusion
(XLIF®), laparoscopic anterior lumbar interbody fusion (LALIF), and minimally
invasive transforaminal lumbar fusion (MITLIF). (See Coverage Limitations
section).

Facet joint replacement/implant is a new device for facet joint degeneration,

which may be used in conjunction with a spinal fusion. It is purported as a
system for facet joint reconstruction, matching the joint shape and size in order
to provide pain relief, normal motion, and stability. An example of this device
includes but may not be limited to the Acadia Facet Replacement System.
Please note: the Acadia is not Food and Drug Administration (FDA) approved;
it is currently in an ongoing clinical trial. (See Coverage Limitations section).

For information regarding artificial intervertebral disc replacement, please refer

to Artificial Intervertebral Disc Replacement Medical Coverage Policy.

For information regarding interspinous process decompression spacers

(X-Stop®), please refer to Interspinous Decompression Spacers Medical
Coverage Policy.

For information regarding non-rigid spinal stabilization devices (Dynesys®

dynamic stabilization system), please refer to Dynamic Spinal Stabilization
Devices Medical Coverage Policy.

See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on
this subject may not be included. This document is for informational purposes only.
 Spinal Fusion Surgery
Original Effective Date: 11/20/2008
Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
Page: 3 of 29

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For information regarding spinal decompression surgery without fusion, please

refer to Spinal Decompression Surgery Medical Coverage Policy.

Coverage Cervical
Determination
Humana members may be eligible under the Plan for cervical fusion surgery
for the following indications as confirmed by radiographic evidence:

As a concurrent stabilization procedure with a corpectomy or laminectomy;

OR

Cervical instability in Down syndrome; OR

Cervical instability in skeletal dysplasia or connective tissue disorders; OR

Degenerative spinal segment adjacent to a previously decompressed or

fused spinal segment with ONE of the following:
 Symptomatic myelopathy corresponding to the adjacent level; OR

 Symptomatic radiculopathy corresponding to the adjacent level and

unresponsive to conservative treatment; OR

Degenerative spondylosis with kyphosis that is causing spinal cord

compression; OR

Disc herniation with radiculopathy and BOTH of the following:

 Failure of conservative treatment; AND

 Unremitting radicular pain or progressive weakness secondary to nerve

root compression; OR

Klippel-Feil syndrome; OR

Multilevel spondylotic myelopathy, as evidenced by ONE of the following:

 Corresponding clinical symptoms (including, but may not be limited to,
bowel or bladder incontinence, clumsiness of hands, frequent falls,

See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on
this subject may not be included. This document is for informational purposes only.
 Spinal Fusion Surgery
Original Effective Date: 11/20/2008
Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
Page: 4 of 29

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urinary urgency) and corresponding objective neurologic signs

(including, but may not be limited to, hyperreflexia, Hoffman sign,
increased tone or spasticity); OR

 Diagnostic imaging positive for cord compression from either herniated

disc or osteophyte; OR

Multilevel spondylotic radiculopathy; OR

Ossification of the posterior longitudinal ligament up to and including three

levels; OR

Spinal abscess/infection; OR

Spinal tumor (primary or metastatic) with associated cord compression,

pathologic fracture or instability; OR

Subluxation or compression due to rheumatoid arthritis; OR

Symptomatic pseudoarthrosis from a prior procedure; OR

Symptomatic spondylosis with instability, as evidenced radiographically by

ONE of the following:
 Subluxation or translation of more than 3.5 mm on static lateral views or
dynamic radiographs; OR

 Sagittal plane angulation of more than 11 degrees between adjacent

segments; OR

 More than 4 mm of motion (subluxation) between the tips of the spinous

processes on dynamic views; OR

Traumatic disc herniation; OR

Unstable injury such as an atlas and axis fracture, burst fracture, facet
fracture with dislocation; OR

Other symptomatic instability or cord or root compression and BOTH of the

following:

See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on
this subject may not be included. This document is for informational purposes only.
 Spinal Fusion Surgery
Original Effective Date: 11/20/2008
Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
Page: 5 of 29

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 Unresponsive to conservative treatment (e.g., rest, medication, cervical

collar); AND

 Imaging study demonstrating corresponding pathologic anatomy

Lumbar

Humana members may be eligible under the Plan for lumbar fusion surgery
for the following indications as confirmed by radiographic evidence:

Severe degenerative scoliosis with ANY of the following:

 Progression of deformity to greater than 50 degrees with loss of
function; OR

 Persistent significant radicular pain or weakness unresponsive to

conservative treatment; OR

 Persistent neurogenic claudication unresponsive to conservative

treatment; OR

Spinal abscess/infection; OR

Spinal dislocation; OR

Spinal fracture with instability or neural compression; OR

Spinal stenosis associated with spondylolisthesis with ONE of the following:

 Progressive or severe symptoms of neurogenic claudication; OR

 Back pain, neurogenic claudication symptoms, or radicular pain

associated with ALL of the following:
 Significant functional impairment; AND

 Listhesis demonstrated on plain x-rays; AND

 Central, lateral recess or foraminal stenosis demonstrated on

See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on
this subject may not be included. This document is for informational purposes only.
 Spinal Fusion Surgery
Original Effective Date: 11/20/2008
Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
Page: 6 of 29

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imaging (e.g., magnetic resonance imaging (MRI), computed

tomography (CT) scan, myelography); AND

 Failure of three months of conservative treatment; OR

Spinal tuberculosis; OR

Spinal tumor; OR

Spondylolysis such as isthmic spondylolisthesis with ONE of the following:

 Progressive deformity or neurologic compromise; OR

 Symptomatic high-grade (i.e., 50% or more anterior slippage)

spondylolisthesis demonstrated on plain x-rays; OR

 Multilevel spondylolysis; OR

 Symptomatic low-grade spondylolisthesis after 6 to 12 months of

conservative treatment.

Thoracic

Humana members may be eligible under the Plan for thoracic fusion surgery
for the following indications as confirmed by radiographic evidence:

Degenerative spondylosis with kyphosis that is causing spinal cord

compression; OR

Severe scoliosis with any of the following:

 Progression of deformity to greater than 50 degrees with loss of
function; OR

 Persistent significant pain or weakness unresponsive to conservative

treatment; OR

 Persistent neurogenic claudication unresponsive to conservative

treatment; OR

See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on
this subject may not be included. This document is for informational purposes only.
 Spinal Fusion Surgery
Original Effective Date: 11/20/2008
Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
Page: 7 of 29

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Spinal abscess or infection; OR

Spinal fractures with instability or neural compression; OR

Spinal tumor.

Coverage Note: A minimally invasive (laparoscopic or endoscopic) approach to spinal

Limitations fusion at any level (cervical, thoracic, or lumbar) is considered integral to the
primary procedure and would not be subject to additional reimbursement on the
part of the surgeon or the facility. This would include, but may not be limited to
the AxiaLIF® XLIF® MITLIF, and/or laparoscopic approach to anterior lumbar
interbody fusion.

Additionally, robotic-assisted surgery and/or robotic guidance systems (e.g.,

Renaissance™ System and SpineAssist Miniature Robotic System) is
considered integral to the primary procedure and not separately reimbursable.

Humana members may NOT be eligible under the Plan for spinal fusion
surgery for any indications other than those listed above. This technology is
considered experimental/investigational or NOT medically necessary if it is not
utilized in accordance with nationally recognized standards of medical practice
and/or identified as safe, widely used and generally accepted as effective for
any other proposed use as reported in nationally recognized peer-reviewed
medical literature published in the English language.

Humana members may NOT be eligible under the Plan for facet joint
replacement/implants, including but not limited to, the Acadia Facet
Replacement System (AFRS). This technology is considered
experimental/investigational as it is not identified as widely used and generally
accepted the proposed use as reported in nationally recognized peer-
reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for Artificial
Intervertebral Disc Replacement. Please refer to Artificial Intervertebral Disc
Replacement Medical Coverage Policy.

See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on
this subject may not be included. This document is for informational purposes only.
 Spinal Fusion Surgery
Original Effective Date: 11/20/2008
Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
Page: 8 of 29

When printed, the version of this document becomes uncontrolled because Humana's documents are updated
regularly. Do not rely on printed copies for the most up-to-date version. Refer to
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Humana members may NOT be eligible under the Plan for Interspinous
Process Decompression Spacers (X-Stop®). Please refer to Interspinous
Decompression Spacers Medical Coverage Policy.

Humana members may NOT be eligible under the Plan for non-rigid spinal
stabilization devices (Dynesys® Dynamic Stabilization System). Please
refer to Dynamic Spinal Stabilization Devices Medical Coverage Policy.

Background You can learn more about degenerative disc disease (DDD), scoliosis,
spondylolisthesis from the following sites:

American Academy of Orthopaedic Surgeons (AAOS) -

http://www.aaos.org

National Library of Medicine - http://www.nlm.nih.gov

North American Spine Society (NASS) - http://www.spine.org

Medical Alternatives to cervical fusion surgery include but may not be limited to the
Alternatives following:

Cervical orthosis (please refer to Orthotics Medical Coverage Policy)

Halo vest for acute injury (please refer to Orthotics Medical Coverage
Policy)

Laminectomy (please refer to Spinal Decompression Surgery Medical

Coverage Policy)

Laminoplasty (please refer to Spinal Decompression Surgery Medical

Coverage Policy)

Physical therapy (please refer to Physical/Occupational Therapy Medical

Coverage Policy )

See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on
this subject may not be included. This document is for informational purposes only.
 Spinal Fusion Surgery
Original Effective Date: 11/20/2008
Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
Page: 9 of 29

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Prescription drug therapy may be appropriate for this condition

Radiation therapy and/or chemotherapy for a spinal tumor.

Alternatives to lumbar fusion surgery include, but may not be limited to the
following:

Back brace (please refer to Orthotics Medical Coverage Policy)

Laminectomy (please refer to Spinal Decompression Surgery Medical

Coverage Policy)

Laminotomy (please refer to Spinal Decompression Surgery Medical

Coverage Policy)

Physical therapy (please refer to Physical/Occupational Therapy Medical

Coverage Policy )

Prescription drug therapy may be appropriate for this condition

Radiation therapy and/or chemotherapy for a spinal tumor.

Alternatives to thoracic fusion surgery include, but may not be limited to the
following:

Back brace (please refer to Orthotics Medical Coverage Policy)

Physical therapy (please refer to Physical/Occupational Therapy Medical

Coverage Policy )

Prescription drug therapy may be appropriate for this condition

Radiation therapy and/or chemotherapy for a spinal tumor.

To make the best health decision for your individual needs, consult your
physician.

See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on
this subject may not be included. This document is for informational purposes only.
 Spinal Fusion Surgery
Original Effective Date: 11/20/2008
Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
Page: 10 of 29

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Provider All provider claims codes surrounding this topic may not be included in the
Claims Codes following table:

CPT© Description Comments

Codes
+20930 Allograft, morselized, or placement of osteopromotive material, for
spine surgery only (List separately in addition to code for primary
procedure)
Allograft, structural, for spine surgery only (List separately in
+20931
addition to code for primary procedure)
+20936 Autograft for spine surgery only (includes harvesting the graft);
local (e.g., ribs, spinous process, or laminar fragments) obtained
from same incision (List separately in addition to code for primary
procedure)
Autograft for spine surgery only (includes harvesting the graft);
+20937 morselized (through separate skin or fascial incision) (List
separately in addition to code for primary procedure)
Autograft for spine surgery only (includes harvesting the graft);
+20938 structural, bicortical or tricortical (through separate skin or fascial
incision) (List separately in addition to code for primary procedure)
Arthrodesis, lateral extracavitary technique, including minimal
22532 discectomy to prepare interspace (other than for decompression);
thoracic
22533 Arthrodesis, lateral extracavitary technique, including minimal
discectomy to prepare interspace (other than for decompression);
lumbar
Arthrodesis, lateral extracavitary technique, including minimal
+22534
discectomy to prepare interspace (other than for decompression);
thoracic or lumbar, each additional vertebral segment (List
separately in addition to code for primary procedure)
Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2
22548 (atlas-axis), with or without excision of odontoid process

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this subject may not be included. This document is for informational purposes only.
 Spinal Fusion Surgery
Original Effective Date: 11/20/2008
Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
Page: 11 of 29

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Arthrodesis, anterior interbody, including disc space preparation, Code

22551 discectomy, osteophytectomy and decompression of spinal cord Effective
and/or nerve roots; cervical below C2 01/01/2011
Arthrodesis, anterior interbody, including disc space preparation,
Code
discectomy, osteophytectomy and decompression of spinal cord
+22552 Effective
and/or nerve roots; cervical below C2, each additional interspace
01/01/2011
(List separately in addition to code for primary procedure)
22554 Arthrodesis, anterior interbody technique, including minimal
discectomy to prepare interspace (other than for decompression);
cervical below C2
Arthrodesis, anterior interbody technique, including minimal
22556 discectomy to prepare interspace (other than for decompression);
thoracic
22558 Arthrodesis, anterior interbody technique, including minimal
discectomy to prepare interspace (other than for decompression);
lumbar
+22585 Arthrodesis, anterior interbody technique, including minimal
discectomy to prepare interspace (other than for decompression);
each additional interspace (List separately in addition to code for
primary procedure)
22590 Arthrodesis, posterior technique, craniocervical (occiput-C2)
22595 Arthrodesis, posterior technique, atlas-axis (C1-C2)
22600 Arthrodesis, posterior or posterolateral technique, single level;
cervical below C2 segment
Arthrodesis, posterior or posterolateral technique, single level;
22610
thoracic (with or without lateral transverse technique)
Arthrodesis, posterior or posterolateral technique, single level;
22612
lumbar (with or without lateral transverse technique)
+22614 Arthrodesis, posterior or posterolateral technique, single level;
each additional vertebral segment (List separately in addition to
code for primary procedure)

See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on
this subject may not be included. This document is for informational purposes only.
 Spinal Fusion Surgery
Original Effective Date: 11/20/2008
Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
Page: 12 of 29

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22630 Arthrodesis, posterior interbody technique, including laminectomy

and/or discectomy to prepare interspace (other than for
decompression), single interspace; lumbar
+22632 Arthrodesis, posterior interbody technique, including laminectomy
and/or discectomy to prepare interspace (other than for
decompression), single interspace; each additional interspace (List
separately in addition to code for primary procedure)
22633 Arthrodesis, combined posterior or posterolateral technique with Code
posterior interbody technique including laminectomy and/or Effective
discectomy sufficient to prepare interspace (other than for 01/01/2012
decompression), single interspace and segment; lumbar
22634 Arthrodesis, combined posterior or posterolateral technique with Code
posterior interbody technique including laminectomy and/or Effective
discectomy sufficient to prepare interspace (other than for 01/01/2012
decompression), single interspace and segment; each additional
interspace and segment (List separately in addition to code for
primary procedure)
22800 Arthrodesis, posterior, for spinal deformity, with or without cast; up
to 6 vertebral segments
22802 Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to
12 vertebral segments
22804 Arthrodesis, posterior, for spinal deformity, with or without cast; 13
or more vertebral segments
22808 Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to
3 vertebral segments
22810 Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to
7 vertebral segments
22812 Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or
more vertebral segments
22818 Kyphectomy, circumferential exposure of spine and resection of
vertebral segment(s) (including body and posterior elements);
single or 2 segments

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this subject may not be included. This document is for informational purposes only.
 Spinal Fusion Surgery
Original Effective Date: 11/20/2008
Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
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22819 Kyphectomy, circumferential exposure of spine and resection of

vertebral segment(s) (including body and posterior elements); 3 or
more segments
22830 Exploration of spinal fusion
+22840 Posterior non-segmental instrumentation (e.g., Harrington rod
technique, pedicle fixation across one interspace, atlantoaxial
transarticular screw fixation, sublaminar wiring at C1, facet screw
fixation) (List separately in addition to code for primary procedure)
+22841 Internal spinal fixation by wiring of spinous processes (List
separately in addition to code for primary procedure)

+22842 Posterior segmental instrumentation (e.g., pedicle fixation, dual

rods with multiple hooks and sublaminar wires); 3 to 6 vertebral
segments (List separately in addition to code for primary
procedure)
+22843 Posterior segmental instrumentation (e.g., pedicle fixation, dual
rods with multiple hooks and sublaminar wires); 7 to 12 vertebral
segments (List separately in addition to code for primary
procedure)
+22844 Posterior segmental instrumentation (e.g., pedicle fixation, dual
rods with multiple hooks and sublaminar wires); 13 or more
vertebral segments (List separately in addition to code for primary
procedure)
+22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately
in addition to code for primary procedure)
+22846 Anterior instrumentation; 4 to 7 vertebral segments (List separately
in addition to code for primary procedure)
+22847 Anterior instrumentation; 8 or more vertebral segments (List
separately in addition to code for primary procedure)
+22851 Application of intervertebral biomechanical device(s) (e.g.,
synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to
vertebral defect or interspace (List separately in addition to code
for primary procedure)

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this subject may not be included. This document is for informational purposes only.
 Spinal Fusion Surgery
Original Effective Date: 11/20/2008
Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
Page: 14 of 29

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Category III Description Comments

CPT©
Codes
0195T Arthrodesis, pre-sacral interbody technique, including
instrumentation, imaging (when performed), and discectomy to
prepare interspace, lumbar; single interspace
+0196T Arthrodesis, pre-sacral interbody technique, including
instrumentation, imaging (when performed), and discectomy to
prepare interspace, lumbar; each additional interspace (List
separately in addition to code for primary procedure)
0202T Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] Not Covered
replacement), including facetectomy, laminectomy, foraminotomy,
and vertebral column fixation, injection of bone cement, when
performed, including fluoroscopy, single level, lumbar spine
0219T Placement of posterior intrafacet implant(s), unilateral or bilateral, Not Covered
including imaging and placement of bone graft(s) or synthetic
device(s), single level; cervical

0220T Placement of posterior intrafacet implant(s), unilateral or bilateral, Not Covered

including imaging and placement of bone graft(s) or synthetic
device(s), single level; thoracic

0221T Placement of posterior intrafacet implant(s), unilateral or bilateral, Not Covered

including imaging and placement of bone graft(s) or synthetic
device(s), single level; lumbar

+0222T Placement of posterior intrafacet implant(s), unilateral or bilateral, Not Covered

including imaging and placement of bone graft(s) or synthetic
device(s), single level; each additional vertebral segment (List
separately in addition to code for primary procedure)

HCPCS© Description Comments

Codes
No specific code identified.

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this subject may not be included. This document is for informational purposes only.
 Spinal Fusion Surgery
Original Effective Date: 11/20/2008
Revised Date: 12/01/2011
Review Date: 12/01/2011
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ICD-9© Description Comments

Procedure
Codes
81.00 Spinal fusion, not otherwise specified
Spinal fusion/ Atlas-axis spinal fusion
81.01 Craniocervical fusion by anterior transoral or posterior technique
C1-C2 fusion by anterior transoral or posterior technique
Occiput C2 fusion by anterior transoral or posterior technique

Spinal fusion; Other cervical fusion of the anterior column, anterior

technique
81.02
Arthrodesis of C2 level or below:
Anterior interbody fusion
Anterolateral technique

Spinal fusion; Other cervical fusion of the posterior column,

81.03 posterior technique

Arthrodesis of C2 level or below, posterolateral technique

Spinal fusion; Dorsal and dorsolumbar fusion of the anterior

column, anterior technique
81.04 Arthrodesis of thoracic or thoracolumbar region:
Anterior interbody fusion
Anterolateral technique
Extracavitary technique

Spinal fusion; Dorsal and dorsolumbar fusion of the posterior

81.05 column, posterior technique

Arthrodesis of thoracic or thoracolumbar region, posterolateral technique

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 Spinal Fusion Surgery
Original Effective Date: 11/20/2008
Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
Page: 16 of 29

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Spinal fusion; Lumbar and lumbosacral fusion, anterior column,

anterior technique

Anterior lumbar interbody fusion [ALIF]

Arthrodesis of lumbar or lumbosacral region:
81.06 Anterior interbody fusion
Anterolateral technique
Retroperitoneal
Transperitoneal
Direct lateral interbody fusion [DLIF]
Extreme lateral interbody fusion [XLIF]
Spinal fusion; Lumbar and lumbosacral fusion of the posterior
column, posterior technique
81.07
Facet fusion
Posterolateral technique
Transverse process technique

Spinal fusion; Lumbar and lumbosacral fusion of the anterior

column, posterior technique
81.08 Arthrodesis of lumbar or lumbosacral region, posterior interbody fusion
Axial lumbar interbody fusion [AxiaLIF]
Posterior lumbar interbody fusion [PLIF]
Transforaminal lumbar interbody fusion [TLIF]

Refusion of spine; Refusion of atlas-axis spine

81.31 Craniocervical fusion by anterior transoral or posterior technique
C1-C2 fusion by anterior transoral or posterior technique
Occiput C2 fusion by anterior transoral or posterior technique

Refusion of spine; Refusion of other cervical spine, anterior

column, anterior technique
81.32
Arthrodesis of C2 level or below:
Anterior interbody fusion
Anterolateral technique

Refusion of spine; Refusion of other cervical spine, posterior

81.33 column, posterior technique

Arthrodesis of C2 level or below; posterolateral technique

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 Spinal Fusion Surgery
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Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
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Refusion of spine; Refusion of dorsal and dorsolumbar spine,

anterior column, anterior technique
81.34 Arthrodesis of thoracic or thoracolumbar region:
Anterior interbody fusion
Anterolateral technique
Extracavitary technique

Refusion of spine; Refusion of dorsal and dorsolumbar spine,

81.35 posterior column, posterior technique

Arthrodesis of thoracic or thoracolumbar region, posterolateral technique

Refusion of spine; Refusion of lumbar and lumbosacral spine,

anterior column, anterior technique

Anterior lumbar interbody fusion [ALIF]

Arthrodesis of lumbar or lumbosacral region:
81.36 Anterior interbody fusion
Anterolateral technique
Retroperitoneal
Transperitoneal
Direct lateral interbody fusion [DLIF]
Extreme lateral interbody fusion [XLIF]

Refusion of spine; Refusion of lumbar and lumbosacral spine,

posterior column, posterior technique
81.37
Facet fusion
Posterolateral technique
Transverse process technique

Refusion of spine; Refusion of lumbar and lumbosacral spine,

anterior column, posterior technique
81.38 Arthrodesis of lumbar or lumbosacral region, posterior interbody fusion
Axial lumbar interbody fusion [AxiaLIF]
Posterior lumbar interbody fusion [PLIF]
Transforaminal lumbar interbody fusion [TLIF]

81.62 Fusion or refusion of 2-3 vertebrae

81.63 Fusion or refusion of 4-8 vertebrae
81.64 Fusion or refusion of 9 or more vertebrae

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 Spinal Fusion Surgery
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Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
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Insertion of interbody spinal fusion device

84.51 Cages (carbon, ceramic, metal, plastic or titanium)

Interbody fusion cage
Synthetic cages or spacers
Threaded bone dowels

84.59 Insertion of other spinal devices

Insertion or replacement of facet replacement device(s)
84.84 Not Covered
Facet arthroplasty

Revision of facet replacement device(s)

84.85 Not Covered
Repair of previously inserted facet replacement device(s)

Medical Abscess - Localized collection of pus surrounded by inflamed tissue.

Terms
Angulation - Abnormal bend or curve.

Axis Fracture - Fracture of the second cervical (C2), also known as axis
vertebra.

Burst Fracture - Injury to the spine in which the vertebral body is severely
compressed. Typically occurs from severe trauma, such as a motor vehicle
accident or a fall from a height.

Chemotherapy - Treatment of disease by means of chemicals that have a

specific toxic effect upon the disease-producing microorganisms or that
selectively destroy cancerous tissue.

Computed Tomography (CT) Scan - Special radiographic technique that uses

a computer to assimilate multiple X-ray images into a two-dimensional cross-
sectional image.

Corpectomy - Surgical procedure that involves removing a substantial part of a

vertebral body.

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Degenerative - Of, relating to, causing, or characterized by degeneration.

Deterioration with corresponding impairment or loss of function.

Down Syndrome - Chromosomal disorder caused by an error in cell division

resulting in the presence of an additional third chromosome 21 or "trisomy 21."

Dysplasia - Abnormal growth or maturation of cells within a tissue.

Facet - Small, smooth area on a bone or other hard surface.

Herniation - To protrude through an abnormal body opening.

Hoffmann Sign - Used to assess patients with symptoms of myelopathy. The

test is done by quickly snapping or flicking the patient's middle fingernail. The
test is positive for spinal cord compression when the tip of the index finger, ring
finger, and/or thumb suddenly flex in response.

Hyperreflexia - Exaggerated response of the deep tendon reflexes, usually

resulting from injury to the central nervous system or metabolic disease.

Klippel-Feil Syndrome - Rare disorder characterized by the congenital fusion

of any two of the seven cervical (neck) vertebrae.

Kyphosis - Abnormal, convex curvature of the spine, with a resultant bulge at

the upper back.

Lamina - Thin plate, sheet, or layer.

Laminectomy - Surgical removal of part of the posterior arch of a vertebra to

provide access to the spinal canal, as for the excision of a ruptured disc.

Laminoplasty - As an alternative to a laminectomy, a surgeon may elect to

expand the spinal canal by repositioning the lamina rather than removing it
completely as in a laminectomy.

Laminotomy - Surgical division of one or more vertebral laminae.

Listhesis - To slip or slide.

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Magnetic Resonance Imaging (MRI) - Special imaging technique that is

utilized to image internal structures of the body; utilizes high powered magnetic
fields rather than X-rays to produce the images.

Myelography - Myelography requires introduction of radiographic contrast

media (dye) into the area surrounding the spinal cord and nerves. It is used to
diagnose disorders of the spinal canal and cord, such as nerve compression.

Myelopathy - Most commonly caused by spinal stenosis, which is a

progressive narrowing of the spinal canal.

Neural - Of, or pertaining to a nerve or the nervous system.

Neurogenic Claudication - Generally a symptom of spinal stenosis, or

inflammation of the nerves originating from the spinal cord. Neurogenic means
that the problem begins with a nerve, and claudication means that the patient
feels a painful cramping and/or weakness.

Orthosis - Device used to support a body part.

Ossification - Condition of being altered into a hard bony substance.

Osteophyte - More commonly known as a bone spur. It is a bony growth that

forms on normal bone.

Pathologic - Caused by or involving disease.

Physical Therapy - Treatment of physical dysfunction or injury by the

therapeutic exercise and the application of modalities, intended to restore or
facilitate normal function or development.

Pseudoarthosis - A false joint formed around a displaced bone after

dislocation.

Radiculopathy - Refers to disease of the spinal nerve roots. Produces pain,

numbness, or weakness radiating from the spine.

Rheumatoid Arthritis - Autoimmune disease that causes chronic inflammation

of the joints.

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Sagittal - Relating to, situated in, to the median plane of the body.

Spondylolysis - Disintegration or dissolution of a vertebra.

Spondylosis - Degenerative disease of the spinal column, especially one

leading to fusion and immobilization of the vertebral bones. The degenerative
process of spondylosis may affect the cervical (neck), thoracic (mid-back), or
lumbar (low back) regions of the spine.

Spondylotic Myelopathy - Refers to myelopathy (spinal cord compression)

due to narrowing (stenosis) of the spinal canal in the cervical (neck) area.

Subluxation - Partial dislocation (as of one of the bones in a joint).

Tuberculosis - Infectious disease that can affect almost any tissues of the
body.

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Chou R, Loeser J, Owens D, et al. Interventional therapies, surgery, and

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ECRI Institute. Custom Hotline Response. Minimally invasive spinal fusion

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this subject may not be included. This document is for informational purposes only.
 Spinal Fusion Surgery
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Revised Date: 12/01/2011
Review Date: 12/01/2011
Policy Number: CLPD-477-003
Page: 22 of 29

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regularly. Do not rely on printed copies for the most up-to-date version. Refer to
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ECRI Institute. Custom Hotline Response. OptiMesh 1500 for spinal fusion.
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dynamic stabilization of the lumbar spine. December 13, 2010. Available at:
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ECRI Institute. Custom Hotline Response. Thoracoscopy for scoliosis. April

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pedicle screw placement during spinal surgery. April 27, 2010. Available at:
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this subject may not be included. This document is for informational purposes only.
 Spinal Fusion Surgery
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Review Date: 12/01/2011
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ECRI Institute. Custom Hotline Response (ARCHIVED). Safety and efficacy of

the VLIFT vertebral body replacement system. July 30, 2008. Available at:
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Hayes, Winifred S. Health Technology Brief. Polyetheretherketone (PEEK)

interbody cages for spinal fusion. October 12, 2011. Available at:
http://www.hayesinc.com. Accessed October 28, 2011.

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Review Date: 12/01/2011
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Hayes, Winifred S. Health Technology Brief (ARCHIVED). Minimally invasive

transforaminal lumbar interbody fusion (MITLIF) for treatment of lumbar disc
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spinal stenosis in older patients. April 22, 2010. Available at:
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Hayes, Winifred S. Prognosis Overview. ACADIA™ Facet Replacement

System (AFRS). February 2011. Available at: http://www.hayesinc.com.
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Arthroplasty System® (TFAS®). September 2009. Available at:
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1®
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options for patients with low back disorders. June 24, 2011. Available at:
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Milliman Care Guidelines® 15th Edition. Cervical fusion, anterior.

Available at: http://cgi.careguidelines.com/login-careweb.htm. Accessed
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Milliman Care Guidelines® 15th Edition. Cervical fusion, posterior.

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Milliman Care Guidelines® 15th Edition. Lumbar fusion.

Available at: http://cgi.careguidelines.com/login-careweb.htm. Accessed
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Neurological Surgeons (AANS). Indications for anterior cervical
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August 2009. Available at: http://www.guideline.gov. Accessed November 17,
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National Guideline Clearinghouse Website. American Association of

Neurological Surgeons (AANS). Laminectomy and fusion for the treatment of
cervical degenerative myelopathy. August 2009. Available at:
http://www.guideline.gov. Accessed November 17, 2011.

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Neurological Surgeons (AANS). Techniques for cervical interbody grafting.
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National Guideline Clearinghouse Website. American College of Occupational

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Accessed November 17, 2011.

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this subject may not be included. This document is for informational purposes only.
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National Guideline Clearinghouse Website. Work Loss Data Institute (WLDI).

Low back – lumbar & thoracic (acute & chronic). 2011. Available at:
http://www.guideline.gov. Accessed November 17, 2011.

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Neck and upper back (acute & chronic). 2011. Available at:
http://www.guideline.gov. Accessed November 17, 2011.

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guidelines for multidisciplinary spine care – diagnosis and treatment of cervical
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guidelines for multidisciplinary spine care – diagnosis and treatment of
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Resnick DK, Choudhri TF, Dailey AT, et al. American Association of

Neurological Surgeons/Congress of Neurological Surgeons. Guidelines for the
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Resnick DK, Choudhri TF, Dailey AT, et al. American Association of

Neurological Surgeons/Congress of Neurological Surgeons. Guidelines for the
performance of fusion procedures for degenerative disease of the lumbar
spine. Part 2: Assessment of functional outcome. J Neurosurg Spine.
2005;2(6):639-646.

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Resnick DK, Choudhri TF, Dailey AT, et al; American Association of

Neurological Surgeons/Congress of Neurological Surgeons. Guidelines for the
performance of fusion procedures for degenerative disease of the lumbar
spine. Part 3: Assessment of economic outcome. J Neurosurg Spine.
2005;2(6):647-652.

Resnick DK, Choudhri TF, Dailey AT, et al; American Association of

Neurological Surgeons/Congress of Neurological Surgeons. Guidelines for the
performance of fusion procedures for degenerative disease of the lumbar
spine. Part 4: Radiographic assessment of fusion. J Neurosurg Spine.
2005;2(6):653-657.

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UpToDate ® Website. Assessment and treatment of ankylosing spondylitis in

adults. October 11, 2011. Available at:
https://www.uptodate.com/home/index.html. Accessed November 16, 2011.

UpToDate ® Website. Complications and management of the

mucopolysaccharidoses. September 2011. Available at:
https://www.uptodate.com/home/index.html. Accessed November 16, 2011.

UpToDate ® Website. Lumbar spinal stenosis: treatment and prognosis.

September 2011. Available at: https://www.uptodate.com/home/index.html.
Accessed November 16, 2011.

UpToDate ® Website. Subacute and chronic low back pain: surgical treatment.
September 22, 2011. Available at: https://www.uptodate.com/home/index.html.
Accessed November 16, 2011.

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UpToDate ® Website. Treatment and prognosis of adolescent idiopathic

scoliosis. September 2011. Available at:
https://www.uptodate.com/home/index.html. Accessed November 16, 2011.

UpToDate ® Website. Treatment of cervical radiculopathy. September 2011.

Available at: https://www.uptodate.com/home/index.html. Accessed November
16, 2011.

UpToDate ® Website. Vertebral osteomyelitis and discitis. September 2011.

Available at: https://www.uptodate.com/home/index.html. Accessed November
16, 2011.

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