General Information
It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.
 

Scope
Spinal Spinal surgeries should be performed only by those with extensive and specialized surgical training (neurosurgery, orthopedic surgery). Choice of surgical approach is based on anatomy, pathology, and the surgeon's experience and preference.

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.

Policy
INDICATIONS
Fusion Surgery (Any Region) for the Treatment of Spinal Neoplasm, Lesion, or Infection
One of the following criteria must be met for urgent intervention:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression due to tumor or infection — immediate surgical evaluation is indicated. Signs or symptoms may include any of the following ^(1,2):
  • Upper extremity weakness
  • Unsteady gait related to myelopathy/balance or generalized
  • Lower extremity weakness
  • Disturbance with coordination
  • Hyperreflexia
  • Hoffmann sign
  • Positive Babinski sign
  • Clonus
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with evidence of spinal cord or nerve root compression due to tumor or infection on magnetic resonance imaging (MRI) or computed tomography (CT) imaging—immediate surgical evaluation is indicated
• When ALL of the following criteria are met:
  • Evidence of gross biomechanical instability resulting in acute neurological risk requiring surgical reconstruction/fusion
  • Imaging studies demonstrate evidence of infection or neoplasm of the spine. Findings must align with corresponding clinical findings. Imaging studies may include:
    • Magnetic resonance imaging (MRI); preferred study for assessing spine soft tissue (including the spinal cord and roots)
    • Computed tomography (CT) - with or without myelography - indicated in individuals who have a contraindication to MRI; preferred for examining the spine’s bony structures

Decompression Surgery (Any Region) for the Treatment of Spinal Neoplasm, Lesion, or Infection ^(3,4,5)
One of the following criteria must be met:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression due to tumor or infection— immediate surgical evaluation is indicated. Signs or symptoms may include any of the following:
  • Upper extremity weakness
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness
  • Lower extremity weakness
  • Disturbance with coordination
  • Hyperreflexia
  • Hoffmann sign
  • Positive Babinski sign
  • Clonus
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with evidence of spinal cord or nerve root compression due to tumor or infection on MRI or CT imaging—immediate surgical evaluation is indicated
• When ALL of the following criteria are met:
  • Clinical exam findings confirm significant radiculopathy or severe axial pain
  • Imaging studies demonstrate evidence of infection or neoplasm of the spine that align with corresponding clinical findings. Imaging studies may include:
    • Magnetic resonance imaging (MRI); preferred study for assessing spine soft tissue (including cord and roots)
    • Computed tomography (CT) - with or without myelography - indicated in individuals who have a contraindication to MRI; preferred for examining the spine’s bony structures

References:

1. Schwake M, Maragno E, Gallus M, Schipmann S, Spille D et al. Minimally Invasive Facetectomy and Fusion for Resection of Extensive Dumbbell Tumors in the Lumbar Spine. Medicina. 2022; 58: 10.3390/medicina58111613.

2. MacLean M, Touchette C, Georgiopoulos M, Brunette-Clément T, Abduljabbar F et al. Systemic considerations for the surgical treatment of spinal metastatic disease: a scoping literature review. The Lancet Oncology. 2022; 23: e321-e333. 10.1016/S1470-2045(22)00126-7.

3. Al Farii H, Aoude A, Al Shammasi A, Reynolds J, Weber M. Surgical Management of the Metastatic Spine Disease: A Review of the Literature and Proposed Algorithm. Global Spine J. 2023; 13: 486-498. 10.1177/21925682221146741.

4. Rispoli R, Reverberi C, Targato G, D'Agostini S, Fasola G et al. Multidisciplinary Approach to Patients with Metastatic Spinal Cord Compression: A Diagnostic Therapeutic Algorithm to Improve the Neurological Outcome. Front Oncol. 2022; 12: 902928. 10.3389/fonc.2022.902928.

5. Zaveri G, Jain R, Mehta N, Garg B. An Overview of Decision Making in the Management of Metastatic Spinal Tumors. Indian J Orthop. 2021; 55: 799-814. 10.1007/s43465-021-00368-8.

Coding Section

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 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 2025 Forward