Lumbar spinal fusion may be considered medically necessary for any one of the following conditions:
Spinal stenosis with both of the following:
Any one of the following
Associated spondylolisthesis demonstrated on plain x-rays, OR
Spinal instability demonstrated on imaging studies, OR
Spinal instability is anticipated due to need for bilateral or wide decompression with facetectomy or resection of pars interarticularis, AND
Either of the following
Neurogenic claudication or radicular pain that results in significant functional impairment in an individual who has failed at least 3 months of conservative care and has documentation of central/lateral recess/or foraminal stenosis on magnetic resonance imaging or other imaging, OR
Severe or rapidly progressive symptoms of motor loss, neurogenic claudication, or cauda equina syndrome.
Severe, progressive idiopathic scoliosis with either of the following:
Cobb angle greater than 40°
Spinal cord compression with neurogenic claudication or radicular pain that results in significant functional impairment in an individual who has failed at least 3 months of conservative care.
Severe degenerative scoliosis (ie, lumbar or thoracolumbar) with a minimum Cobb angle of 30°, or significant sagittal imbalance (eg, sagittal vertical axis >5 cm), and with any one of the following:
Documented progression of deformity with persistent axial (nonradiating) pain and impairment or loss of function unresponsive to at least 1 year of conservative therapy
Persistent and significant neurogenic symptoms (claudication or radicular pain) with impairment or loss of function, unresponsive to at least 1 year of conservative nonsurgical care
Severe or rapidly progressive symptoms of motor loss, neurogenic claudication, or cauda equina syndrome.
Isthmic spondylolisthesis, when all of the following are present:
Congenital (Wiltse type I) or acquired pars defect (Wiltse type II), documented on x-ray, and:
Persistent back pain (with or without neurogenic symptoms), with impairment or loss of function
Either unresponsive to at least 3 months of conservative nonsurgical care or with severe or rapidly progressive symptoms of motor loss, neurogenic claudication, or cauda equina syndrome.
Recurrent, same-level disc herniation, at least 3 months after previous disc surgery, when all of the following are present:
Recurrent neurogenic symptoms (radicular pain or claudication) or evidence of nerve root irritation, as demonstrated by a positive nerve root tension sign or positive femoral tension sign or a corresponding neurologic deficit
Impairment or loss of function
Unresponsive to at least 3 months of conservative nonsurgical care or with severe or rapidly progressive symptoms of motor loss, neurogenic claudication, or cauda equina syndrome
Neural structure compression and instability documented by imaging at a level and side corresponding to the clinical symptoms.
Pseudarthrosis, documented radiologically, when all of the following are present:
No less than 6 months after initial fusion
With persistent axial back pain, with or without neurogenic symptoms, or with severe or rapidly progressive symptoms of motor loss, neurogenic claudication, or cauda equina syndrome
Impairment or loss of function, in an individual who had experienced significant interval relief of prior symptoms.
Instability due to fracture, dislocation, infection, abscess, or tumor when extensive surgery is required that could create an unstable spine.
Iatrogenic or degenerative flatback syndrome with significant sagittal imbalance; when fusion is performed with spinal osteotomy or interbody spacers.
Adjacent-level disease when all of the following are present:
Persistent back pain (with or without neurogenic symptoms) with impairment or loss of function that is unresponsive to at least 3 months of conservative therapy
Eccentric disc space collapse, spondylolisthesis, acute single-level scoliosis, or lateral listhesis on imaging
Symptoms and functional measures correlate with imaging findings
The previous fusion resulted in significant relief for at least 6 months.
Lumbar spinal fusion is considered investigational if the sole indication is any one of the following conditions:
Disc herniation
Chronic nonspecific low back pain without radiculopathy
Degenerative disc disease
Initial discectomy/laminectomy for neural structure decompression
Facet syndrome.
Lumbar spinal fusion is considered not medically necessary for any indication not addressed above.
Multiple-level lumbar spinal fusion is considered not medically necessary when the criteria listed above are not met for all levels.
