Cervical laminectomy may be considered medically necessary when ALL of the following conditions are met:
Spinal cord or nerve root compression due to one of the following conditions:
Spinal stenosis (with or without spondylolisthesis)
Ossification of the posterior longitudinal ligament or the yellow ligament; or hypertrophy of the ligamentumflavum.
Signs and/or symptoms that meet at least one of the following criteria:
Neurologic deficits that are rapidly progressive; OR
Symptoms of cervical myelopathy (see Policy Guidelines section) or cervical cord compression (with or without radiculopathy); OR
Persistent debilitating pain that is refractory to at least 6 weeks of conservative nonsurgical therapy (See Policy Guidelines section).
Imaging studies (preferably magnetic resonance imaging) with findings of spinal cord compression, nerve root compression, and/ormyelographic changes, at a level corresponding to the patient’s signs and symptoms.
Lumbar laminectomy may be considered medically necessary when ALL of the following conditions are met:
Spinal cord or nerve root compression due to spinal stenosis (with or without spondylolisthesis);
Signs and/or symptoms that meet at least one of the following criteria:
Neurologic deficits that are rapidly progressive; OR
Neurologic claudication that is persistent and refractory to at least 6 weeks of conservative nonsurgical therapy (see Policy Guidelines section); OR
Persistent debilitating pain that is refractory to at least 6 weeks of conservative nonsurgical management (see Policy Guidelines section).
Imaging studies (preferably magnetic resonance imaging) with findings of spinal cord or nerve root compression, at a level corresponding to the patient’s signs and symptoms.
Laminectomy (cervical, thoracic, lumbar) may be considered medically necessary for space-occupying lesions of the spinal cord and/or spinal canal.
Primary or metastatic tumors
Abscesses or other localized infections.
Laminectomy (cervical or lumbar) is investigational for spinal stenosis when the above criteria are not met.
Laminectomy is considered investigational for all other indications.
