Lumbar Spinal Procedures - CAM 161

Policy and Guidelines 
INDICATIONS FOR LUMBAR SPINE SURGERY:
Lumbar Discectomy/Microdiscectomy: Surgical indications for inter-vertebral disc herniation*: 

  • When ALL of the following are present::
    • Primary radicular symptoms noted upon clinical exam that significantly hinders daily activities (Chou, 2009; Kreiner, 2014; Tosteson, 2011); AND
    • Failure to improve with at least 6 consecutive weeks in the last 6 months of  documented, physician directed appropriate conservative treatment to include at least 2 of the following (Delitto, 2015; Kreiner, 2014, 2013):
      • Analgesics, steroids, and/or NSAIDs
      • Structured program of physical therapy
      • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician
      • Epidural steroid injections and or selective nerve root block; AND
    • Imaging studies showing evidence of inter-vertebral disc herniation that correlate exactly with the patient's symptoms/ signs (Fardon, 2014; Kreiner, 2014); OR 

*Other Indications: Microdiscectomy may be used as the first line of treatment (no conservative treatment required) in the following clinical scenarios (Kreiner, 2014): 

  • Progressive nerve compression resulting in an acute neurologic deficit (motor) due to herniated disc. The neurological deficits should be significant: 0-2/5 on the motor function scale for LS or Sl roots; 0-3/5 for L3 or L4 roots. Lesser degrees of motor dysfunction may resolve with conservative treatment and are not considered an indication for early surgery; OR
  • Cauda equina syndrome (loss of bowel or bladder control). 

NOTE: Percutaneous lumbar discectomy, radiofrequency disc decompression, and related procedures are deemed investigational procedures and are not approved. Discectomy and microdiscectomy are the gold standards. 

Lumbar Decompression: Laminectomy, Laminotomy, Facetectomy, and Foraminotomy. These procedures us parts of vertebral bone and ligaments. Surgical ecompression due to lumbar spinal stenosis*: 

  • When ALL of the following are present:
    • Neurogenic claudication, and/or radicular leg pain that impairs daily  activities (Atlas, 2005; Chou, 2009; Genevay, 2010; Kreiner, 2013; Tosteson, 2011, 2008; Weinstein, 2007); AND
    • Failure to improve with at least 6 consecutive weeks in the last 6 months of  documented, physician directed appropriate conservative therapy to include at least two (2) of the following (Delitto, 2015; Kreiner, 2013):
      • Analgesics, steroids, and/or NSAIDs
      • Structured program of physical therapy
      • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician
      • Epidural steroid injections and or selective nerve root block; AND
    • Imaging findings demonstrating moderate to severe stenosis consistent with clinical signs/symptoms (Genevay, 2010; Kreiner, 2013; Weinstein, 2007); OR

 *Other Indications: Lumbar decompression may be used as the first line of treatment (no conservative treatment required) in any of the following clinical scenarios (Kreiner, 2014, 2013): 

  • Progressive nerve compression resulting in an acute neurologic (motor) deficit. The neurological deficits should be significant-0-2/5 on the motor function scale for LS or Sl roots; 0-3/5 for L3 or L4 roots. Lesser degrees of motor dysfunction may resolve with conservative treatment and are not considered an indication for early surgery; OR
  • Cauda equina syndrome (loss of bowel or bladder control); OR
  • Spinal stenosis due to tumor, infection, or trauma 

NOTE: Percutaneous decompressions, endoscopic decompression, and related procedures (laser, etc.) are deemed investigational procedures and are not approved. Open or microdecompressions via laminectomy or laminotomy are the gold standards (Kreiner, 2014). 

Lumbar Spine Fusion:
Single Level Fusion With or Without Decompression:
Because of variable outcomes with fusion surgery, patients should be actively involved in the decision making process and provided appropriate decision-support materials explaining potential risks/ benefits/ and treatment alternatives when considering this intervention. 

  • When All of the following are present*:
    • Lumbar back pain, neurogenic claudication, and/or radicular leg pain without sensory or motor deficit that impairs daily activities for at least 6 months (Bogduk, 2009; Brox, 2010; Carreon, 2008; Chou, 2009; Eck, 2014; Fritzell, 2001; Kreiner, 2013; Mannion, 2016; Matz,
    • 2014, 2016; NASS, 2009; Tosteson,  2011, 2008; Weinstein, 2007); AND
    • Failure to improve with at least 6 consecutive weeks in the last 6 months of  documented, physician directed appropriate conservative therapy (6 months for isolated LBP) to include at least two (2) of the following (Brox, 2010; Chou, 2009; Eck, 2014; Delitto, 2015; Kreiner, 2013; Matz, 2014, 2016; NASS, 2009)
      • Analgesics, steroids, and/or NSAIDs
      • Structured program of physical therapy
      • Structured home exercise program prescribed by a physical therapist, hiropractic provider or physician
      • Epidural steroid injections and or facet injections /selective nerve root block; AND
    • Imaging studies corresponding to the clinical findings (Eck, 2014; Genevay,  2010; Kreiner, 2013; Matz, 2014, 2016; NASS, 2009; Weinstein, 2007); AND
    • At least one of the following clinical conditions:
      • Spondylolisthesis [Neural Arch Defect -Spondylolytic spondylolisthesis, degenerative spondylolisthesis, and congenital unilateral neural arch hypoplasia] (Carreon, 2008; Kwon, 2005; Matz, 2014, 2016; NASS, 2009; Weinstein, 2007; Yavin, 2017); OR
      • Evidence of segmental instability -Excessive motion, as in degenerative spondylolisthesis, segmental instability, and surgically induced segmental instability (Carreon, 2008; Kwon, 2005; Matz, 2014, 2016; NASS, 2009; Weinstein, 2007; Yavin, 2017); OR 
      • Revision surgery for failed previous operation(s) for pseudoarthrosis at the same level at least 6-12 months from prior surgery** if significant functional gains are anticipated (Trumees, 2017); OR
      • Revision surgery for failed previous operation(s) repeat disk herniations if  significant functional gains are anticipated (Note: Many recurrent disc herniations can be treated with discectomy alone, so specific indications for the addition of fusion will be required) (Kreiner, 2014); OR
      • Fusion for the treatment of spinal tumor, cancer, or infection (Trumees, 2017); OR
      • Chronic  low  back pain or  degenerative disc disease (disc degeneration without significant neurological compression presenting with low back pain) must have failed at least 6 months of appropriate active non-operative treatment (completion of a comprehensive cognitive-behavioral rehabilitation program is mandatory) and must be evaluated on a case-by-case basis (Bogduk, 2009; Brox, 2010; Chou, 2009; Fardon, 2014; Fritzell, 2001; Mannion, 2016; Yavin, 2017). 

NOTE: The results of several randomized trials suggests that in many degenerative cases uninstrumented posterolateral intertransverse fusion has similar results to larger instrumented (PLIF, TLIF, etc.) fusion techniques with fewer morbidities and less likelihood of  revision surgery. Accordingly, specific findings suggesting more significant instability should be present when larger techniques are used (gaping of facets, gross motion on  flexion / extension radiographs, wide disc spaces) (Carreon, 2008; Deyo, 2010; Endler, 2017; Yavin, 2017); OR 

*Other Indications: Lumbar spinal fusion may be used as the first line of treatment (no conservative treatment required) in the following clinical scenarios (Kreiner, 2014): 

  • Progressive nerve compression resulting in an acute neurologic deficit (motor); AND
    • One of the aforementioned clinical conditions, except chronic low back pain or degenerative disc disease. The neurological deficits must be significant: 0-2/5 on the motor function scale for LS or S1 roots; or 0-3/5 for L3 or L4 roots. Lesser degrees of motor dysfunction may resolve with conservative treatment and are not considered an indication for early surgery.
  • Cauda equina syndrome (loss of bowel or bladder control); AND
    • One of the aforementioned clinical conditions, except chronic low back pain or degenerative disc disease. 

** REPEAT LUMBAR SPINE FUSION OPERATIONS: Repeat lumbar fusion operations will be reviewed on a case-by-case basis upon submission of medical records and imaging studies that demonstrate remediable pathology. The below must also be documented and available for review of repeat fusion requests (Bogduk, 2009; Chou, 2009; Mannion, 2016; Yavin, 2017): 

  • Rationale as to why surgery is preferred over other non-invasive or less invasive treatment procedures.
  • Signed documentation that the patient has participated in the decision-making process and understands the high rate of failure/complications. 

Multi-level Fusion with or without decompression (all multi-level fusion surgeries will be reviewed on a case-by-case basis):
Because of variable outcomes with fusion surgery, patients should be actively involved in the decision making process and provided appropriate decision-support materials explaining potential risks/ benefits/ and treatment alternatives when considering this intervention. 

  • When ALL of the following are present*:
    •  Lumbar back pain, neurogenic claudication, and/or radicular leg pain without sensory or motor deficit that impairs daily activities for at least 6 months (Bogduk 2009; Brox  2010; Chou 2009; Fritzell 2001; Mannion 2016; Tosteson 2011, 2008; Weinstein, 2007); AND
    •  Failure to improve with at least 6 consecutive weeks in the last 6 months of  documented, physician directed appropriate conservative therapy to include at least two (2) of the following {Brox, 2010; Delitto, 2015; Matz, 2014, 2016; NASS, 2009):
      • Analgesics, steroids, and/or NSA!Ds
      • Structured program of physical therapy
      • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician
      • Epidural steroid injections and or facet injections /selective nerve root block; AND
    • Imaging studies corresponding to the clinical findings {Eck, 2014; Genevay, 2010; Kreiner, 2013; Matz, 2014, 2016; NASS, 2009; Weinstein, 2007); AND
    • At least one of the following clinical conditions {Carreon, 2008; Kwon, 2005; Matz, 2014, 2016; NASS, 2009; Yavin, 2017):
      • Multiple level spondylolisthesis {Note: Fusions in cases with single level spondylolisthesis should be limited to the unstable level); OR
      • Fusion for the treatment of spinal tumor, trauma, cancer, or infection affecting multiple levels; OR
      • Intra-operative segmental instability; OR

*Other Indications: Lumbar spinal fusion may be used as the first line of treatment {no conservative treatment required) in the following clinical scenarios (Kreiner, 2014):

  • Progressive nerve compression resulting in an acute neurologic deficit  (motor); AND
    • One of the aforementioned clinical conditions except chronic low back pain or degenerative disc disease. The neurological deficits must be significant: 0-2/5 on the motor function scale for LS or 51roots; or 0-3/5 for L3 or L4 roots. Lesser degrees of motor dysfunction
  • may resolve with appropriate conservative treatment and are not considered an indication for early surgery; OR
  • Cauda equina syndrome {loss of bowel or bladder control); AND
    • One of the aforementioned clinical conditions, except chronic low back pain or degenerative disc disease.

Lumbar Artificial Disc Replacement
Because of variable outcomes with lumbar artificial disc replacement surgery, patients should be actively involved in the decision-making process and provided appropriate decision-support materials when considering this intervention.

Lumbar total disc arthroplasty {artificial disc replacement) may be considered MEDICALLY NECESSARY when ALL of the following indications are met (Jacobs, 2013; NASS, 2019; Radcliff, 2018; Zigler, 2012, 2017):

  • The individual is between the ages of 18 to 60
  • Degenerative disc disease or significant discogenic back pain with disc  degeneration, is confirmed by documented patient history, physical examination, and key  radiographic studies, with no more than Grade 1 (low level) spondylolisthesis demonstrated on X-ray at the operative levels
  • Imaging confirms absence of significant facet arthropathy at operative levels
  • At least six months of non-operative (conservative) treatment have failed to resolve symptoms (See Note*)
  • Disc reconstruction with the device is performed at one or two consecutive  levels in the lumbar spine from L3-Sl using an anterior retroperitoneal approach
  • The device used as the disc replacement device is FDA-approved for lumbar disc replacement and is used in accordance with FDA labelling
  • There are no contraindications to lumbar artificial disc replacement, including but not limited to (see Note**):
    • Disease above L3-4
    • Active systemic or local infection
    • Osteoporosis or osteopenia (DEXA bone mineral density T-score less than or  equal to - 1.0), or vertebral bodies compromised by disease or prior trauma
    • Allergy or sensitivity to implant materials
    • Isolated lumbar radiculopathy (especially due to herniated disc), or chronic  radiculopathy (unremitting especially leg symptoms lasting over 1 year)
    • Spinal stenosis, or spinal deformity (scoliosis)
    • Spondylolisthesis greater than Grade 1
    • Disc degeneration requiring treatment at more than two levels
    • Severe facet arthrosis or joint degeneration
    • Presence of free disc fragment
    • Poorly managed psychiatric disorder

Artificial lumbar disc replacement is considered NOT MEDICALLY NECESSARY in all other circumstances, including artificial disc arthroplasty done at more than two spinal levels, and hybrid (combination artificial disc and fusion) procedures.

NOTE*:  Conservative care is focused multi-modal nonoperative treatment that must include a physical therapy/rehabilitation program with cognitive-behavioral components. Treatment may also include pain management injections and active exercise programs. This must be clearly outlined in the medical record.

NOTE**: Contraindications are related to the levels being considered for surgery.

Percutaneous Sacroiliac Joint (SIJ) Fusion (all SIJ fusion surgeries will be reviewed on a case-by-case basis):
Because of variable outcomes with fusion surgery, patients should be actively involved in the decision making process and provided appropriate decision-support materials when considering this intervention.

  • When ALL of the following are present (NASS, 2015; Polly, 2016; Whang, 2019):
  • Low back/buttock pain that is typically unilateral and caudal to the lumbar spine localized over the SIJ that impairs daily activities for at least 6 months; AND
  • Failure to improve with at least 6 months of appropriate active non-operative treatment that must include medications, PT, and a home exercise program; AND
  • Physical exam demonstrating pain to palpation over the sacral sulcus in the absence of tenderness of similar severity elsewhere; AND
  • Absence of generalized pain behavior; AND
  • Positive pain response to a cluster of 3 provocative tests (e.g., thigh thrust, compression test, Gaenslen's test, distraction test, Faber test); AND
  • Diagnostic imaging studies that include ALL of the following:
    • Imaging (plain radiographs and a CT or MRI) of the SI joint that excludes the presence of destructive lesions (e.g., tumor, infection) or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion
    • Imaging of the pelvis (AP plain radiograph) to rule out concomitant hip pathology
    • Imaging of the lumbar spine (CT or MRI) to rule out neural compression or  other degenerative condition that can be causing low back or buttock pain
    • Imaging of the SI joint that indicates evidence of injury and/or degeneration;  AND
  • At least 75% reduction of pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra-articular SIJ injection on 2 separate occasions; AND
  • A trial of at least one therapeutic intra-articular SIJ injection (i.e., corticosteroid injection)

NOTE: Instrumentation, bone formation or grafting materials, including biologics, should be used at  the surgeon's discretion; however, use should be limited to FDA approved indications regarding the specific devices or biologics.

NOTE: This lumbar surgery guideline does not address spinal deformity surgeries or the clinical indications for spinal deformity surgery.

NOTE: Pre-sacral, axial lumbar interbody fusion (AxiaLIF) is not an approved surgical approach due to insufficient evidence..

RELATIVE CONTRAINDICATIONS FOR SPINE SURGERY (NOTE: Cases may not be approved if the below contraindications exist):

  • Medical contraindications to surgery, e.g., severe osteoporosis; infection of  soft tissue adjacent to the spine and may be at risk for spreading to the spine; severe cardiopulmonary disease; anemia; malnutrition and systemic infection (Puvanesarajah, 2016).
  • Psychosocial risk factors. It is imperative to rule out non-physiologic modifiers of pain presentation or non- operative conditions mimicking radiculopathy or instability  (e.g., peripheral neuropathy, piriformis syndrome, myofascial pain, sympathetically mediated pain syndromes, sacroiliac dysfunction, psychological conditions, etc.) prior to consideration of  elective surgical intervention (Kreiner, 2014). Patients with clinically significant depression or other psychiatric disorders being considered for elective spine surgery will be reviewed on a case-by-case basis and the surgery may be denied for risk of failure.
  • Morbid Obesity. Contraindication to surgery in cases where there is significant risk and concern for improper post-operative healing, post-operative complications related to morbid obesity, and/or an inability to participate in post-operative rehabilitation (Epstein, 2017). These cases will be reviewed on a case-by-case basis and may be denied given the risk of  failure.

Rationale
Lumbar Discectomy/Microdiscectomy is a surgical procedure to remove part of the damaged spinal disc. The damaged spinal disc herniates into the spinal canal and compresses the nerve roots. Nerve root compression leads to symptoms like low back pain, radicular pain, numbness and tingling, muscular weakness, and paresthesia. Typical disc herniation pain is exacerbated with any  movement  that causes the disc to increase pressure on the nerve roots.

Lumbar Decompression   (Laminectomy, Laminotomy, Facetectomy, and Foraminotomy): Laminectomy is a common decompression surgery. The American Association of Neurological Surgeons defines laminectomy  as a surgery to remove the back part of vertebra, lamina, to create more space for the spinal cord and nerves. The most common indication for laminectomy is spinal stenosis. Spondylolisthesis and herniated disk are also frequent indications for laminectomy. Decompression surgery is usually performed as part of lumbar fusion surgery.

Lumbar Fusion Surgery: Lumbar spinal fusion (arthrodesis) is a surgical procedure used to treat spinal conditions of the lumbar, e.g., degenerative disc disease, spinal stenosis, injuries/fractures of the spine, spinal instability, and spondylolisthesis. Spinal fusion is a "welding" process that permanently fuses or joins together two or more adjacent bones in the spine, immobilizing the vertebrae and restricting motion at a painful joint. It is usually performed after other surgical procedures of the spine, such as discectomy or laminectomy. The goal of fusion is to increase spinal stability, reduce irritation of the affected nerve roots, compression on the spinal cord, disability, and pain and/or numbness. Clinical criteria for single level fusion versus multiple level fusions are outlined under the indications section.

Lumbar Artificial Disc Replacement: Lumbar artificial disc replacement (LADR) is a surgical procedure used to treat low back pain from lumbar degenerative disc disease. The degenerative lumbar disc is replaced with an artificial disc that maintains motion at the surgical level. Studies have shown the results of LADR to be at least equivalent to spinal fusion for the treatment of  discogenic  low  back pain. LADR is a technically challenging operation and proper training should be obtained before performing the procedure.

OVERVIEW
This guideline outlines the key surgical treatments and indications for common lumbar spinal disorders and is a consensus document based upon the best available evidence. Spine surgery is a complex area of medicine and this document breaks out the treatment modalities for lumbar spine disorders into surgical categories: lumbar discectomy/microdiscectomy, lumbar decompression, lumbar fusion surgery, and lumbar artificial disc replacement. See below for procedures considered not medically necessary.

  • Spinal surgeries should be performed only by those with extensive surgical training (neurosurgery, orthopaedic surgery)
  • Services Not Covered: The following procedures are considered either still under investigation or are not recommended based upon the current evidence: Percutaneous lumbar discectomy; Laser discectomy; Percutaneous Radiofrequency Disc Decompression; intradiscal electrothermal annuloplasty (IDEA) or more commonly called IDET (lntradiscal Electrothermal therapy); Nucleus Pulpous Replacement; and Pre-Sacral Fusion.
    • PERCUTANEOUS DISCECTOMY is an invasive operative procedure to accomplish partial removal of the disc through a needle which allows aspiration of a portion of the disc under imaging control. Its only indication is to obtain diagnostic tissue, such as, for a biopsy for  discitis. Its effectiveness has not been fully established.
    • LASERDISCECTOMY is a procedure which involves the delivery  of  laser  energy  into the center of the nucleus pulposus using a fluoroscopically guided laser fiber under  local anesthesia. The energy denatures protein in the nucleus, causing a structural change which is intended to reduce intradiscal pressure. Its effectiveness has not been fully established.
    • INTRAD/SCAL ELECTROTHERMAL ANNULOPLASTY (IDEA) (more commonly coiled /DET, or  lntrodiscal Electrothermal therapy) is an outpatient non-operative procedure in which a wire is guided into the identified painful disc using fluoroscopy. The wire is then heated at the nuclear-annular junction within the disc. It has not been shown to be effective.
    • NUCLEUSPULPOSUS REPLACEMENT  Involves the introduction of a prosthetic implant into the intervertebral disc, replacing the nucleus pulposus while preserving the annulus fibrosus. It has not been shown to be effective relative to other gold standard interventions.
  • Conservative Therapy: (Musculoskeletal) includes primarily physical therapy  and /or injections; and a combination of modalities, such as rest, ice, heat, modified activities, medical devices (such as braces), medications, diathermy, chiropractic treatments, or physician supervised home exercise program.
  • Home Exercise Program (HEP) - the following two elements are required to meet guidelines for completion of conservative therapy:
    • Documentation provided of an exercise prescription/plan; AND
    • Follow up with member with information provided regarding completion of HEP (after suitable 4 – 6 week period), or inability to complete HEP due to physical reason- i.e. increased pain, inability to physically perform exercises. (Patient inconvenience or noncompliance without  explanation does not constitute "inability to complete" HEP).
  • Isolated Low Back Pain• Pain isolated to the lumbar region of the spine and the surrounding paraspinal musculature. Also referred to 'mechanical low back pain' or 'discogenic pain'. No associated neurogenic claudication or radiculopathy.
  • Claims Billing & Coding:
    • NIA uses a combination of internally developed edits in addition to an enhanced set of industry standard editing. NIA's Claims Edit Module is a group of system edits that run multiple times per day. Edits that are part of this module include industry standard edits that apply to spine surgery services and NIA custom edits developed specifically for spine surgery. The following describes each of the edits NIA applies:
  • Outpatient Code Editor (OCE): This edit performs all functions that  require specific reference to HCPCS codes, HCPCS modifiers, and ICD-9-CM diagnosis codes. The OCE only functions on a single claim and does not have any cross claim capabilities. NIA is consistent with CMS.
  • National Correct Coding Initiative (NCCI) editing: The edit prevents improper payment when incorrect code combinations are reported. The NCCI contains two tables of edits. The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table include code pairs that should not be reported together for a number of reasons explained in the Coding Policy Manual. NIA is consistent with CMS.
    • Incidental edits: This edit applies if a procedure being billed is a component of another procedure that occurred on the same date of service for the same provider and tax ID and claimant.
    • Mutually exclusive editing: This edit applies if a procedure being billed is mutually exclusive with a procedure that occurred on the same date of service for the same provider tax ID and claimant.
  • Multiple Procedure Discounts (MPD): This edit applies a reduction to the second and any other subsequent services by the same provider, in the same setting, for the same member. We typically apply a 50% reduction. NIA follows the CMS methodology that began in January 2011 which allows for application of MPD to codes within CMS's two specific advanced imaging code families. However, NIA differs from CMS in that we apply MPD to all provider types unless health plan contracts prohibit this.
  • Lumbar Fusion• Fusions can be performed either anteriorly, laterally, or  posteriorly, or via a combined approach, although simple posterolateral fusions are indicated in the great majority of cases requiring fusion. Aggressive surgical approaches to fusion may be an indication for denial of cases (when such techniques have not been demonstrated to be superior to less morbid techniques) or recommendation for alternative procedure. These are the surgical approaches:
  • lntertransverse Fusion or Posterolateral Fusion
  • Anterior lnterbody Fusion (ALIF}
  • Lateral or Transpsoas lnterbody Fusion (XLIF}
  • Posterior or Trans-foraminal lnterbody Fusion (PLIF or TLIF)
  • Anterior/posterior Fusion (360-degree)
  • Pre-sacral, axial lumbar interbody fusion (AxiaLIF) is still being investigated and is not recommended.
  • Use of bone grafts including autologous or allograft which might be combined with metal or biocompatible devices to produce a rigid, bony connection between two or more adjacent vertebrae are common. Bone formation or grafting materials including biologics should be used at the surgeon's discretion; however, use of biologics should be limited to FDA approved indications in order to limit complications (especially BMP).
  • All operative interventions must be based upon positive correlation of clinical findings, clinical course, and diagnostic tests and must be performed by surgeons with appropriate training (neurosurgery, orthopaedic surgery). A comprehensive assimilation of these factors must lead to a specific diagnosis with positive identification of pathologic condition(s). A failure of accurate correlation may be an indication for denial of cases. It is imperative to rule out non-physiologic modifiers of pain presentation or non-operative conditions mimicking radiculopathy or instability (e.g., peripheral neuropathy, piriformis syndrome, myofascial pain, sympathetically mediated pain syndromes, sacroiliac dysfunction, psychological conditions, etc.) prior to consideration of elective surgical intervention.
  • Operative treatment is indicated when the natural history of surgically treated lesions is better than the natural history for non-operatively treated lesions.
    • All patients being considered for surgical intervention should first undergo a comprehensive neuro- musculoskeletal examination to identify mechanical pain generators that may respond to non-surgical techniques or may be refractory to surgical intervention.
    • While sufficient time allowances for non-operative treatment are required to determine the natural cause and response to non-operative treatment of low back pain disorders, timely decision making for operative intervention is critical to avoid de-conditioning and increased disability (exclusive of "emergent" or urgent pathology such as cauda equina syndrome or associated rapidly progressive neurologic loss).
  • In general, if the program of non-operative treatment fails, operative treatment is indicated when:
    • Improvement of the symptoms has plateaued or failed to occur and the residual symptoms of pain and functional disability are unacceptable at the end of 6 to 12 weeks of active treatment, or at the end of longer duration of non-operative programs for debilitated patients with complex problems; and/or
    • Frequent recurrences of symptoms cause serious functional limitations even if  a non operative active treatment program provides satisfactory relief of symptoms, and restoration of function on each recurrence.
  • Lumbarspinal stenosis and associated lumbar spondylolisthesi: Spinal stenosis is narrowing of the spinal column or of the neural foramina where spinal nerves leave the spinal column. The most common cause is degenerative change in the lumbar spine. Neurogenic claudication is the most common symptom, referring to "leg symptoms encompassing the buttock, groin and anterior thigh, as well as radiation down the posterior part of the leg to the feet." In addition to pain, leg symptoms can include fatigue, heaviness, weakness and/or paresthesia. Some patients may also suffer from accompanying back pain. Symptoms are worse when standing or walking and are relieved by sitting. Lumbar spinal stenosis is often a disabling condition, and it is the most common reason for lumbar spinal surgery in adults over 65 years.
  • Degenerative lumbar spondylolisthesis is the displacement of a vertebra in the lower part of the spine; one lumbar vertebra slips forward on another with an intact neural arch and begins to press on nerves. The slippage occurs at the L4-L5 level most commonly. The most common cause, in adults, is degenerative disease although it may also result from bone diseases and fractures. Spondylolisthesis seldom occurs  before the age of 50 years and it disproportionately affects women, especially black women. Degenerative spondylolisthesis is not always symptomatic. The indications for fusion in this group are evolving and as more evidence emerges, changes to the accepted indications and acceptable techniques used may be made.
  • Lumbar degenerative disease without stenosis or spondylolisthesis:  Spondylosis is an umbrella term describing age-related degeneration of the spine. Lumbar  degenerative disease without stenosis or spondylolisthesis is characterized by disabling low back pain and spondylosis at L4-5, L5-S1, or both levels.

References 

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  18. Jacobs W, Van der Gaag NA, Tuschel A, et al. Total disc replacement for chronic discogenic low back pain: A Cochrane Review. Spine. 2013 Janl; 38(1):24-36.
  19. Kreiner DS, Hwang SW, Easa JE, et al. An evidence based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014 Jan; 14(1):180-91.
  20. Kreiner DS, Shaffer WO, Baisden JL, et al. An evidence-based clinical guideline for the diagnosis and treatmentof degenerative lumbar spinal stenosis. Spine J. 2013; 13(7):734-43.
  21. Kwon BK, Hilibrand AS, Malloy K, et al. A critical analysis of the literature regarding surgical approach and outcome for adult low-grade isthmic spondylolisthesis. J Spinal Disord Tech. 2005; 18(1):S30-40. http://www.ncbi.nlm.nih.gov/pubmed/15699803.
  22. Mannion AF, Brox JI, Fairbank JC. Long-term results of all RCTs show that fusion is no better than non operative care in improving pain and disability in chronic low back pain. Spine J. 2016; 16:588-90.
  23. Matz PG, Meagher RJ, Lamer T, et al. Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis 2"d Edition. North American Spine Society. 2014:1-121. https://www.spine.org/Documents/ResearchCIinica!Care/GuideIines/SpondyloIisthesis.pdf.
  24. Matz PG, Meagher RJ, Lamer T, et al. Guideline summary review: An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine J. 2016 Mar; 16(3):439-48.
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Coding Section

Code Number Description
CPT 22533 ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR
  22558 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR
  22612 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)
  22630 ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE; LUMBAR
  22633 ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE AND SEGMENT; LUMBAR
  22534 ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC OR LUMBAR, EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
  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)
  22614 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 
  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) 
  22634 ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE AND SEGMENT; EACH ADDITIONAL INTERSPACE AND SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 
  22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to  prepare interspace (other than for decompression), single interspace, lumbar 
  22862
Revision including replacement of total disc  arthroplasty (artificial disc), anterior  approach, single interspace; lumbar
  22865 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace;  lumbar 
  27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed and placement of transfixing device
  27280 Arthrodesis, open, sacroiliac joint, including obtaining bone graft, including instrumentation, when performed 
  63030 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar 
  63035

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure) 

  63005

Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis 

  63012

Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) 

  63017

Laminectomy with exploration and/or decompression of spinal cord and/or caudaequina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar 

  63042

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar  

  63044

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace (List separately in addition to code for primary procedure)  

  63047

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar  

  63048

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) 

  63052 (code effective on 01/01/2022)  

Laminectomy, facetectomy, or foraminotomy with lumbar decompression of spinal cord, cauda equina and/or nerve root during posterior interbody arthrodesis, single segment 

  63053 (code effective on 01/01/2022)  

Laminectomy, facetectomy, or foraminotomy with lumbar decompression of spinal cord, cauda equina and/or nerve root, during posterior interbody arthrodesis, each additional segment 

  63056

Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc) 

  63057

Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure) 

  62380

Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2017 Forward     

04/01/2022 

Annual review, no change to policy intent. 

11/29/2021 

Updating policy with 2022 coding. Adding code 63052 and 63053. No other change made. 

05/10/2021 

Correcting relative contraindication section. No change to policy intent. 

04/01/2021 

Corrected annual review date from 4/2021 to 4/2022. 

03/09/2021 

Annual review, adding policy verbiage for two level lumbar artificial disc replacement. Also updating rationale and references. 

01/21/2021 

Interim review to add clarification to the list of contraindications for lumbar disc replacement. No other changes. 

12/28/2020 

Reformatting for clarity. 

09/24/2020 

Updating coding. Adding code 63048 to coding section. No other changes. 

08/12/2020 

Updating coding. Adding codes 63030 and 63047. No change to intent to policy.

05/14/2020 

Interim review, updating conservative treatment language to include "in the last 6 months". Add lumbar Artificial Desc replacement and update policy. Also changing annual review to July. 

03/02/2020 

Annual review, no change to policy intent. 

9/30/2019 

Interim review to remove contraindication related to nicotine use to align with CAM 142. No other changes made. 

03/04/2019 

Annual review, no change to policy intent. 

03/19/2018 

Annual review, no change to policy intent

12/11/2017 

Updating policy with 2018 coding. No other changes made. 

03/22/2017

New Policy

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