Medical Policies - Surgery


Cervical and Thoracic Spinal Fusion

Number:SUR712.041

Effective Date:10-15-2017

Coverage:

Cervical fusion may be considered medically necessary when the patient has:

Cervical nerve root compression (as documented by MRI), consistent with the symptomatic levels of cervical radiculopathy, AND

o Persistence of debilitating radicular pain (see NOTE #1) despite non-surgical conservative therapy (see NOTE #2) for at least 3 months, or,

o Neurogenic claudication or progressive symptoms of motor loss that impairs function; OR

Cervical kyphosis associated with cord compression (as documented by MRI); OR

Symptomatic pseudarthrosis (non-union of prior fusion) associated with mechanical instability or deformity of the cervical spine; OR

Spinal fracture, dislocation (associated with mechanical instability), locked facets, or displaced fracture fragment; OR

Spinal infection; OR

Spinal tumor, primary or metastatic to spine; OR

Atlantoaxial (C1-C2) subluxation (e.g., associated with congenital anomaly, os odontoideum, or rheumatoid arthritis) noted as widening of the atlantodens interval greater than 3 mm; OR

Basilar invagination of the odontoid process into the foramen magnum; OR

Subaxial (C2-T1) instability when both of the following are met:

o Significant instability (sagittal plane translation of at least 3 mm on flexion and extension views or relative sagittal plane angulation greater than 11 degrees); and

o Symptomatic unremitting pain that has failed 3 months of conservative management; OR

Adjunct to excision of synovial cysts causing spinal cord or nerve root compression with unremitting pain, and with corresponding neurological deficit, where symptoms have failed to respond to six weeks of conservative therapy (unless there is evidence of cord compression, or progressive neurological deficit, which requires urgent intervention); OR

Clinically significant deformity of the spine (kyphosis, head-drop syndrome, post-laminectomy deformity) that meets any of the following criteria:

o The deformity prohibits forward gaze; or

o The deformity is associated with severe neck pain, difficulty ambulating, and interference with activities of daily living; or

o Documented progression of the deformity.

Thoracic fusion may be considered medically necessary when the patient has:

Thoracic nerve root compression (osteophytic spurring, ligamentous hypertrophy) at the appropriate side and level, OR

Persistence of debilitating radicular pain (see NOTE #1) despite non-surgical conservative therapy for at least 3 months (see NOTE #2), or neurogenic claudication, or progressive symptoms of motor loss that impairs function, OR

Scoliosis, with Cobb angle greater than 40 degrees in skeletally immature children and adolescents, or Cobb angle greater than 50 degrees associated with functional impairment in skeletally mature adults, OR

Thoracic kyphosis resulting in spinal cord compression, or kyphotic curve greater than 75 degrees that is refractory to bracing, OR

Symptomatic pseudarthrosis (non-union of prior fusion), with mechanical instability or deformity of the thoracic spine that has failed 3 months of conservative management; or

Spinal fracture, dislocation (associated with mechanical instability), locked facets, or displaced fracture fragment, which may be combined with a laminectomy, OR

Spinal infection, OR

Spinal tumor, primary or metastatic to spine, OR

Spondylolisthesis with segmental instability when both of the following criteria are met:

o Significant spondylolisthesis, grades II, III, IV, or V; and

o Symptomatic unremitting pain that has failed 3 months of conservative management; OR

Severe spinal stenosis with persistent debilitating pain, that has failed 3 months of conservative management when any of the following is met:

o Decompression is performed in an area of segmental instability as manifested by gross movement on flexion-extension radiographs; or

o Decompression coincides with an area of significant degenerative instability (e.g., scoliosis or any degree of spondylolisthesis (grades I, II, III, IV or V); or

o Decompression creates an iatrogenic instability by the disruption of the posterior elements where facet joint excision exceeds 50% bilaterally or complete excision of one facet is performed.

Unless one of the above conditions is met, cervical or thoracic spinal fusion surgical procedures are considered not medically necessary.

NOTE #1: Persistent debilitating pain is defined as significant level of pain on a daily basis defined on a Visual Analog Scale (VAS) as greater than 4; that has a documented impact on activities of daily living.

NOTE #2: Conservative non-surgical therapy of cervical or thoracic radiculopathy typically consists of, but is not limited to the following modalities:

Use of prescription strength oral analgesics (including anti-inflammatory medications, if not contraindicated); AND

A short course of oral corticosteroids, if not contraindicated; AND

Participation in a physical therapy program with active exercise and gradual mobilization; AND

Evaluation and appropriate management of associated cognitive, behavioral or addiction issues if and when present.

Description:

Spinal Fusion

Spinal fusion (arthrodesis) is a surgical technique to stabilize the spinal bones or vertebrae. The goal of fusion is to create a solid bridge of bone between two or more vertebrae so that motion no longer occurs between them. Bone grafts are placed around the spine during surgery. The body then heals the grafts over several months similar to healing a fracture, which joins the vertebrae together. Spinal fusion may be recommended for many reasons including but not limited to: treatment of a fractured (broken) vertebra; correction of deformity (spinal curves or slippages); elimination of pain from painful motion; treatment of instability; and treatment of some cervical disc herniations.

There are many surgical approaches and methods available to fuse the spine, and they all involve placement of a bone graft between the vertebrae. The spine may be approached and the graft placed from the back (posterior approach), from the front (anterior approach) or by a combination of both. In the neck, the anterior approach is more common; lumbar and thoracic fusion is more commonly performed posteriorly.

Fusion may or may not involve use of supplemental hardware (instrumentation) such as plates, screws and cages. Instrumentation is sometimes used to correct a deformity, but usually is used as an internal splint to hold the vertebrae together while the bone grafts heal. Whether or not hardware is used, it is important that bone or bone substitutes be used to get the vertebrae to fuse together. The bone may be taken either from another bone in the patient (autograft) or from a bone bank (allograft). (1)

Cervical Spinal Fusion

There are seven cervical vertebrae. They are stacked one on top of another and are separated by discs, which act as an elastic cushions or shock absorbers. The first two vertebrae are an exception and do not have discs. Discs have a soft center, the nucleus, surrounded by a tough outer ring, the annulus. Discs allow motion between the vertebrae. The interbody space is the disc space that is located between the vertebral body bones. Each vertebral segment creates a bony circle, called the spinal canal that protects the spinal cord and spinal nerves.

Approximately 15% to 20% of adults report experiencing neck pain in any given year. A common cause of neck pain is degenerative disc disease (DDD), a disorder in which the discs in the neck lose elasticity and cause settling of the spinal column structure and abnormal spinal motions. DDD is a consequence of aging and may lead to the development of bone spurs (spondylosis), osteoarthritis, and/or a herniation of a cervical disc. These processes can result in peripheral nerve root impingements or radiculopathy. Common symptoms of radiculopathy include neck and arm pain and weakness, tingling, or numbness in the upper extremities. Symptomatic patients often improve with conservative treatment, including nonsteroidal anti-inflammatory drugs, steroids, epidural steroids, and physical therapy. If these conservative approaches fail, surgery may be indicated. -

One common surgical technique is anterior cervical discectomy with fusion (ACDF), which is performed under general anesthesia. The surgery is performed through a small incision on the front of the neck, usually in the neck’s natural crease. The trachea (windpipe), esophagus (stomach tube), and blood vessels lie in front of the spine and are carefully moved aside. Once the surgeon safely creates a window to see the spine, the damaged disc is partially removed with surgical tools. This is called a discectomy. Some of the disc wall is intentionally left behind to help contain bone graft material. Once the disc space has been cleared out, the surgeon prepares the bony surfaces for a fusion. The bones are slightly spread apart to make more room for the bone graft. This distracts the bones to realign proper curvature and enlarges the openings to relieve pressure off any pinched nerves.

A cage implant that may be filled with bone graft is placed in the now empty disc space between the two vertebral bodies. The spacer or fusion cage may be made of bone, titanium, or plastic. Bone graft inside the disc space will go on to fuse, healing the two bones together in this area. Benefits of fusion in the anterior interbody space include an increased area for bone to heal, as well as increased forces that are distributed through this area when the patient stands and walks. If the fusion is successful, the vertebrae will only move as one unit. This reduces future problems at this spinal segment. If the bones do not fuse as planned this is called a nonunion, or pseudarthrosis.

Thoracic Fusion

There are twelve thoracic vertebrae, named T1-T12, specialized for stability. The thoracic spine aids in keeping the body upright, protects vital chest organs and articulates with each rib to form the rib cage. Each rib is firmly connected to each level of the thoracic spine. The thoracic spine has a kyphotic shape, a “C” shape, and the discs in this part of the spine are relatively thin.

Thoracic Posterior Instrumented Fusion (PIF)

A PIF is performed under general anesthesia. The spinal surgeon will make a small incision on the back to approach the spine. From here, the spinal surgeon can fuse the posterior elements of the spine. Fusion is accomplished with spinal instrumentation including pedicle screws, rods and using bone graft. This is done to accomplish fusion or augment a staged procedure. PIF is often the second part of a staged surgery. In these cases, the posterior instrumentation may be required for further decompression and stabilization after an interbody fusion. This may be indicated for osteoporosis. If bones do not have optimal strength measured by a DXA scan, the bones may not be strong enough to hold a fusion together while new bone grows. Some patients with severe spinal stenosis may require a more extensive decompression to free up severely narrowed nerve space.

Rationale:

Cervical Spine

Cervical Radiculopathy

In a prospective randomized study (2013) conducted by Peolsson et al. (4) the objective was to investigate differences in physical functional outcome in patients with radiculopathy due to cervical disc disease, after structured physiotherapy alone (consisting of neck-specific exercises with a cognitive-behavioral approach) versus after anterior cervical decompression and fusion (ACDF) followed by the same structured physiotherapy program. No earlier studies have evaluated the effectiveness of a structured physiotherapy program or postoperative physical rehabilitation after ACDF for patients with magnetic resonance imaging-verified nerve compression due to cervical disc disease. Sixty-three patients with radiculopathy and magnetic resonance imaging-verified nerve root compression, which were randomized to receive either ACDF in combination with physiotherapy or physiotherapy alone. For 49 of these patients, an independent examiner measured functional outcomes, including active range of neck motion, neck muscle endurance, and hand-related functioning before treatment and at 3-, 6-, 12-, and 24-month follow-ups. There were no significant differences between the 2 treatment alternatives in any of the measurements performed (P = 0.17-0.91). Both groups showed improvements over time in neck muscle endurance (P≤0.01), manual dexterity (P≤0.03), and right-handgrip strength (P = 0.01). Compared with a structured physiotherapy program alone, ACDF followed by physiotherapy did not result in additional improvements in neck active range of motion, neck muscle endurance, or hand-related function in patients with radiculopathy. The authors suggest that a structured physiotherapy program should precede a decision for ACDF intervention in patients with radiculopathy, to reduce the need for surgery.

A meta-analysis by Gao et al. (5) compared the results of cervical disc arthroplasty with anterior cervical discectomy and fusion (ACDF) for the treatment of symptomatic cervical disc disease. Only randomized clinical trials were included in this meta-analysis, and the search strategy followed the requirements of the Cochrane Library Handbook. Two reviewers independently assessed the methodological quality of each included study and extracted the relevant data. Twenty-seven randomized clinical trials were included; twelve studies were Level I and fifteen were Level II. The results of the meta-analysis indicated longer operative times, more bloodloss, lower neck and arm pain scores reported on a visual analog scale, better neurological success, greater motion at the operated level, fewer secondary surgical procedures, and fewer such procedures that involved supplemental fixation or revision in the arthroplasty group compared with the anterior cervical discectomy and fusion group. These differences were significant (p<0.05). The two groups had similar lengths of hospital stay, Neck Disability Index scores, and rates of adverse events, removals, and reoperations (p>0.05). The meta-analysis revealed that anterior cervical discectomy and fusion was associated with shorter operative times and less blood loss compared with arthroplasty. Other outcomes after arthroplasty (length of hospital stay, clinical indices, range of motion at the operated level, adverse events, and secondary surgical procedures) were superior or equivalent to the outcomes after anterior cervical discectomy and fusion.

UpToDate 2016: Treatment of Cervical Radiculopathy (6)

Summary and Recommendations:

The optimum treatment of compressive cervical radiculopathy is the subject of continued debate, and there is little convincing evidence that any treatment improves upon the natural history of the condition.

Limited data suggest that most patients with compressive cervical radiculopathy improve without specific treatment.

For patients with cervical radiculopathy who have clear radicular pain and symptoms of paresthesia, numbness, or nonprogressive neurologic deficits, we suggest conservative therapy as initial treatment. Typically treatment begins with oral analgesics (e.g., nonsteroidal anti-inflammatory drugs), avoidance of provocative activities, and add a short course of oral prednisone if pain is severe. Once the pain is tolerable, initiation of physical therapy with exercise and gradual mobilization.

Symptoms of cervical radiculopathy may recur in up to one-third of patients after initial improvement. Conservative management should be reemployed if symptoms recur unless a significant motor deficit or myelopathy is present.

For patients with confirmed cervical radiculopathy who have severe or disabling pain despite a reasonable course of conservative therapy, and who do not have a progressively worsening neurologic deficit, suggest the use of epidural steroid injections rather than surgery. The injections should be performed by experienced centers and interventionalists under fluoroscopic guidance using test contrast injection to identify accidental vessel injection.

The benefit of surgery for the treatment of cervical radiculopathy has not been clearly established, and data from controlled trials are sparse. For patients with cervical radiculopathy who have all of the following conditions, we suggest surgery rather than nonsurgical therapy:

Symptoms and signs of cervical radiculopathy,

Cervical nerve root compression by MRI or CT myelography at the appropriate side and level(s),

Persistence of radicular pain despite nonsurgical therapy for at least 6 to 12 weeks, or progressive motor weakness that impairs function.

Other Conditions (Cervical Fracture, Instability, Kyphosis, Spondylolysis and Disc Herniations)

The North American Spine Society (NASS) notes the following as potential reasons for a surgeon to consider fusing the vertebrae. These include:

Treatment of a fractured (broken) vertebra; correction of deformity (spinal curves or slippages); elimination of pain from painful motion; treatment of instability; and treatment of some cervical disc herniations.

One of the less controversial reasons to do spinal fusion is a vertebral fracture. Although not all spinal fractures need surgery, some fractures - particularly those associated with spinal cord or nerve injury - generally require fusion as part of the surgical treatment. Sometimes a hairline fracture allows one vertebra to slip forward on another. This condition is called spondylolisthesis and can be treated by fusion surgery.

Another condition that is treated by fusion surgery is actual or potential instability. Instability refers to abnormal or excessive motion between two or more vertebrae. It is commonly believed that instability can either be a source of back or neck pain or cause potential irritation or damage to adjacent nerves. Although there is some disagreement on the precise definition of instability, many surgeons agree that definite instability of one or more segments of the spine is an indication for fusion.

Cervical disc herniations that require surgery usually need not only removal of the herniated disc (discectomy), but also fusion. With this procedure, the disc is removed through an incision in the front of the neck (anteriorly) and a small piece of bone is inserted in place of the disc. Although disc removal for a disc herniation is commonly combined with fusion in the neck, this is not generally true in lumbar disc herniations. Spinal fusion is sometimes considered in the treatment of a painful spinal condition without clear instability. A major obstacle to the successful treatment of spine pain by fusion is the difficulty in accurately identifying the source of a patient’s pain. The theory is that pain can originate from painful spinal motion and fusing the vertebrae together to eliminate the motion will get rid of the pain. Unfortunately, current techniques to precisely identify which of the many structures in the spine could be the source of a patient’s back or neck pain are not perfect. Because it can be so hard to locate the source of pain, treatment of back or neck pain alone by spinal fusion is somewhat controversial. Fusion under these conditions is usually viewed as a last resort and should be considered only after other conservative (nonsurgical) measures have failed.

Thoracic Spine

Scoliosis

Anterior spinal fusion with instrumentation has been used for many years in the treatment of thoracolumbar and lumbar curves in adolescent idiopathic scoliosis (AIS). Tis et al. (2010) reported the intermediate radiographical and pulmonary function testing (PFT) data from patients who underwent open instrumented anterior spinal fusion (OASF) using modern, rigid instrumentation for the treatment of primary thoracic (Lenke 1) adolescent idiopathic scoliosis (AIS). Of 101 potential patients who underwent OASF with a minimum 5-year follow-up, 85 (85 %) were studied. Standing radiographs were analyzed before surgery and at first standing erect, 2-year, and 5-year follow-up. Data on PFT were collected before surgery and at 5 years after surgery. Complete 5-year follow-up was obtained in 85 patients. Five years after surgery, the mean coronal correction was 26 degrees (51 %; p < 0.05) and the thoracolumbar/lumbar curve improved 16 degrees (51 %). There was a 9-degree (p < 0.001) increase in kyphosis, and there were 9 patients (11 %) in whom the C7 plumb line translated greater than 2 cm. There was a 6.7 % decrease in predicted forced expiratory volume in one second over the 5-year period, from 75.5 % +/- 13 % before surgery to 68.8 % +/- 2 % at 5-year follow-up (p = 0.007); however, there was no significant change in forced vital capacity. There were 3 significant adverse events: 1 implant breakage requiring re-operation and 2 cases of progression of the main thoracic curve requiring re-operation. The authors concluded that OASF is a reproducible and safe method to treat thoracic AIS. It provides good coronal and sagittal correction of the main thoracic and compensatory thoracolumbar/lumbar curves that is maintained with intermediate term follow-up. In skeletally immature children, this technique can cause an increase in kyphosis beyond normal values, and less correction of kyphosis should be considered during instrumentation. As with any procedure that employs a thoracotomy, pulmonary function is mildly decreased at final follow-up.

In a retrospective review, Kelly and colleagues (2010) evaluated a group of patients based on Scoliosis Research Society (SRS)-30 and Oswestry data as well as radiographical and MRI findings; and reported the results of long-term follow-up of anterior spinal fusion with instrumentation for thoracolumbar and lumbar curves in AIS. Eighteen patients were available for review. Average follow-up for this study was 16.97 years. Based on SRS-30 and the Oswestry Disability Index data, most patients had good function scores and acceptable pain levels. Radiographs demonstrated no progression of the thoracolumbar or thoracic curves. Implant failure was identified in 2 patients. Radiographical changes of early degenerative disc disease were identified in most patients but had no correlation with SRS or Oswestry data. These degenerative changes were evident on both radiographs and MRI. The authors concluded that the anterior approach in the treatment of thoracolumbar and lumbar curves in AIS offers good long-term functional outcomes for patients. Despite expected degenerative changes, patients scored well on the SRS and Oswestry tests, and were able to pursue careers and family activities.

UpToDate 2016 – Scoliosis (10)

The primary goal of surgical treatment of adolescent idiopathic scoliosis (AIS) is prevention of curve progression through spinal fusion, but there is limited evidence regarding this outcome. Successful fusion occurs in approximately 95 percent of cases. Surgical correction is indicated for skeletally immature patients with curves with Cobb angle ≥50º and some skeletally immature patients with Cobb angle between 40 and 50º. Surgical correction also is an option for skeletally mature patients with Cobb angle ≥50º. Surgery also may be warranted for patients with lumbar curves with marked trunk shift.

Guidelines and Society Positions

American College of Occupational and Environmental Medicine (ACOEM) and the Work Loss Data Institute (13)

Guidelines written by the American College of Occupational and Environmental Medicine (ACOEM) and the Work Loss Data Institute were published in 2011. Based on a limited evidence base, the ACOEM report on cervical and thoracic spine disorders, recommends cervical spinal fusion for patients with degenerative spondylolisthesis.

North American Spine Society (NASS) (8)

Based on fair evidence for degenerative cervical radiculopathy, the NASS in 2010 indicated that:

Both anterior cervical discectomy (ACS) and ACDF are suggested as comparable treatment strategies, producing similar clinical outcomes.

The addition of an interbody graft for fusion is suggested to improve sagittal alignment following ACD [anterior cervical discectomy].

Both ACDF with and without a plate are suggested as comparable treatment strategies, producing similar clinical outcomes and fusion rates.

The addition of a cervical plate is suggested to improve sagittal alignment following ACDF.

While plate stabilization may be indicated in some patients undergoing multilevel ACDF, there is insufficient evidence that this practice results in significant improvement in clinical outcomes for degenerative cervical radiculopathy.

Either ACDF or posterior laminoforaminotomy (PLF) are suggested for the treatment of single level degenerative cervical radiculopathy secondary to foraminal soft disc herniation to achieve comparably successful clinical outcomes.

Compared to PLF, ACDF is suggested for the treatment of single level degenerative cervical radiculopathy from central and paracentral nerve root compression and spondylotic disease.

ACDF and total disc arthroplasty (TDA) are suggested as comparable treatments, resulting in similarly successful short term outcomes.

In addition, the NASS released the following document:

Appropriate Use Criteria for Cervical Fusion:

The objective of NASS Appropriate Use Criteria is to define appropriate (meaning reasonable) care of spinal disorders. This document is intended to reflect contemporary treatment concepts and to assist in the delivery of optimum, efficacious treatment and functional recovery. The criteria do not represent a “standard of care,” nor are they intended as a fixed treatment protocol.

However, it does provide an evidence-based review to help guide decision-making for patients, providers, payers and policy makers. The 2013 criteria note the following:

“Regarding the variables examined, fusion for degenerative conditions that resulted in axial pain tended to be less appropriate than those resulting in radiculopathy. These in turn tended to be slightly less appropriate than in the setting of myelopathy unless severe neurological deficit was present, in which case there was approximate equivalence. Along the same lines, fusion for degenerative conditions with central stenosis was most consistently rated as appropriate followed by those with foraminal stenosis followed by conditions with no radiographic stenosis. The presence of signal changes in the spinal cord on MRI with central stenosis tended to be associated with stronger support for fusion in some select scenarios, but the ratings were mostly equivalent to similar scenarios without cord signal changes. In the presence of neurological problems, either myelopathy or radiculopathy, both short and long fusions were often considered appropriate. In contrast, for conditions without stenosis or causing axial pain only, one level (versus multilevel disease) was more likely to be considered appropriate for fusion, if at all.

In general, anterior fusion was appropriate regardless of sagittal alignment. Posterior fusion was more often appropriate with kyphosis than lordosis, although this was felt to be appropriate for several scenarios with lordosis, as well. Trends for anterior and posterior surgery were rare except for patients undergoing corpectomy, and, to improve fusion rates. The longer the fusion, the more likely combined anterior and posterior surgery was felt to be appropriate. There was consistent support for revision fusion for pseudarthrosis if it was symptomatic and just as consistent lack of support for fusion for asymptomatic pseudarthroses. The exceptions to the latter were patients with some element of central stenosis and persistent neurological problems, particularly myelopathy.

Finally, comorbidities definitely affected appropriateness of cervical fusion, including smoking, medical and psychosocial problems. The more severe the comorbidities, the more caution there was to support fusion. These variables resulted in stronger opposition for conditions with axial complaints and for conditions without stenosis than for conditions with radiculopathy and with foraminal stenosis. They had the least effect on conditions with central stenosis and cervical myelopathy.”

National Guideline Clearinghouse - AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care Cervical and thoracic spine disorders. (2012) (36)

Radicular Pain Syndromes

Cervical discectomy with fusion to speed recovery in patients with chronic radiculopathy due to ongoing nerve root compression who continue to have significant pain and functional limitation after at least 6 weeks of time and appropriate non-operative therapy. The intervention is recommended for appropriate patients and has nominal costs and essentially no potential for harm. The Evidence-based Practice Panel (EBPP) feels that the intervention constitutes best medical practice to acquire or provide information in order to best diagnose and treat a health condition and restore function in an expeditious manner. The EBPP believes based on the body of evidence, first principles, or collective experience that patients are best served by these practices, although the evidence is insufficient for an evidence-based recommendation.

Myelopathy- Decompressive surgery (laminoplasty, laminectomy, discectomy with fusion)

The intervention is recommended for appropriate patients and has nominal costs and essentially no potential for harm. The EBPP feels that the intervention constitutes best medical practice to acquire or provide information in order to best diagnose and treat a health condition and restore function in an expeditious manner. The EBPP believes based on the body of evidence, first principles, or collective experience that patients are best served by these practices, although the evidence is insufficient for an evidence-based recommendation.

Spinal Stenosis

Decompression with fusion for patients with symptomatic spinal stenosis that is intractable to non-operative management.

Spondylolisthesis

Fusion for degenerative spondylolisthesis (C). The intervention is recommended for appropriate patients. There is limited evidence that the intervention may improve important health and functional benefits.

Spinal fusion as an option at the time of discectomy if a patient is having a simultaneous discectomy on the same disc. The intervention is recommended for appropriate patients and has nominal costs and essentially no potential for harm. The Evidence-based Practice Panel (EBPP) feels that the intervention constitutes best medical practice to acquire or provide information in order to best diagnose and treat a health condition and restore function in an expeditious manner. The EBPP believes based on the body of evidence, first principles, or collective experience that patients are best served by these practices, although the evidence is insufficient for an evidence-based recommendation.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

CODING:

Disclaimer for coding information on Medical Policies

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.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

20930, 20936, 22532, 22534, 22548, 22551, 22552, 22554, 22556, 22590, 22595, 22600, 22610, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22853, 22854, 22859, [Deleted 1/2017: 22851]

HCPCS Codes

None

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.

A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov.

References:

1. North American Spine Society. ‘Know your back’. Spinal Fusion. Available at: <http://www.knowyourback.org> Assessed on April 6, 2016.

2. Boselie, TF, Willems, PC, van, MH, de Bie, RA, Benzel, EC, and van, SH. Arthroplasty versus fusion in single-level cervical degenerative disc disease: a Cochrane review. Spine (Phila Pa 1976). 2013; 38(17):E1096-E1107. PubMed 23656959 [PMID]

3. Yin, S, Yu, X, Zhou, S, Yin, Z, and Qiu, Y. Is cervical disc arthroplasty superior to fusion for treatment of symptomatic cervical disc disease? A meta-analysis. Clin Orthop Relat Res. 2013; 471(6):1904-1919. PMID 23389804

4. Peolsson A, Söderlund A, et al. Physical function outcome in cervical radiculopathy patients after physiotherapy alone compared with anterior surgery followed by physiotherapy: a prospective randomized study with a 2-year follow-up. Spine (Phila Pa 1976). 2013; 38(4):300. PMID 23407407

5. Gao Y, Liu M, Li T, et al. A meta-analysis comparing the results of cervical disc arthroplasty with anterior cervical discectomy and fusion (ACDF) for the treatment of symptomatic cervical disc disease. J Bone Joint Surg Am 2013; 95(6):555-561. PMID 23515991

6. Robinson, J, Kothari, MJ, Treatment of cervical radiculopathy In: UpToDate Post TW (Ed), UpToDate, Waltham, MA. Topic last updated: February 4, 2016. Available at: <http://www.uptodate.com> (Accessed on April 4. 2016).

7. National Guideline Clearinghouse - AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care Cervical and thoracic spine disorders. (2012)

8. North American Spine Society (NASS) Appropriate Use Criteria for Cervical Fusion. 2013 Available at: <http://www. > (Accessed on April 4. 2016).

9. American Association of Neurological Surgeons. Patient Information Cervical Spine. Available at: <http://www.aans.org>. Accessed on April 11. 2016.

10. Scherl, SA, Adolescent idiopathic scoliosis: Management and prognosis. In: UpToDate Post TW (Ed), UpToDate, Waltham, MA. Topic last updated: March 2, 2016. Available at: <http://www.uptodate.com> (Accessed on April 4. 2016). 39

11. Karaikovic EE, Pacheco HO. Treatment options for thoracolumbar spine fractures. Bosn J Basic Med Sci. 2005; 5(2):20-26.

12. Cervical and thoracic spine disorders. In: Hegmann KT, editor(s). Occupational medicine practice guidelines. Evaluation and management of

13. Common health problems and functional recovery in workers. 3rd ed. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2011. p. 1-332.

Policy History:

Date Reason
10/15/2017 Reviewed. No changes.
2/1/2017 New medical document. Significant coverage criteria regarding cervical and thoracic fusion. See coverage section.

Archived Document(s):

Title:Effective Date:End Date:
Cervical Spinal Fusion09-15-202101-14-2023
Cervical Spinal Fusion04-01-202009-14-2021
Cervical and Thoracic Spinal Fusion10-15-201703-31-2020
Cervical and Thoracic Spinal Fusion02-01-201710-14-2017
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