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Medical PolicySubject: Cervical and Lumbar Spinal ProceduresMedical Policy #: 25.1Original Effective Date: 05/17/2010Status: ReviewedLast Review Date: 05/26/2021DisclaimerRefer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefiton all plans or the plan may have broader or more limited benefits than those listed in this Medical Policy.Coverage DeterminationPrior Authorization is required, Log on to the NIA Magellan website: www.RadMD.com to submit a “Request anExam”.Presbyterian now uses NIA Magellan Lumbar Spinal Surgery.NIA prior authorizes or manage the provider precertification for Musculoskeletal Surgery Services, and not the facilityprecertification. Musculoskeletal Surgery Services rendered through the Emergency Room are not managed by NIA. All otherinpatient and outpatient Musculoskeletal surgery procedures are managed by NIA for the surgeries outlined below.This Medical Policy includes information on the following items (Ctrl Click to select):Lumbar Spine SurgeryLumbar Spine SurgeryDescriptionIndicationExclusionCodingLumbar Spinal Fusion (single level) SurgeryLumbar Spinal Fusion (multiple levels) SurgeryLumbar Decompression ProceduresLumbar Discectomy/Microdiscectomy procedureCervical Spine r Cervical Decompression with Fusion (ACDF) Single levelAnterior Cervical Decompression with Fusion (ACDF) – Multiple level:Cervical Posterior Decompression with Fusion – Single LeveCervical Posterior Decompression with Fusion- Multiple Levels:Cervical Artificial Disc – Single Level:Cervical Artificial Disc – Two Levels:Cervical Posterior Decompression (without fusion):Cervical Anterior Decompression (without fusion):LUMBAR SPINAL SURGERYNot every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule ofBenefits to determine coverage [MPMPPC051001].1
LumbarSpineSurgeryLumbar Spinal Fusion SurgeryLumbar Decompression ProceduresLumbar Microdiscectomy Only ProceduresDescriptionThis guideline outlines the key surgical treatments and indications for common lumbar spinal disordersand is a consensus document based upon the best available evidence. Spine surgery is a complex areaof medicine and this document breaks out the treatment modalities for lumbar spine disorders intosurgical categories: lumbar discectomy/microdiscectomy, lumbar decompression, and lumbarfusion surgery.Artificial disc replacement is an alternative to spinal fusion for the treatment of symptomatic disc disease.These devices are designed to maintain the function of the natural spine by preserving motion, and topotentially limit the incidence of adjacent segment degeneration. Presbyterian Health Plan coverscervical artificial disc replacement, but does not cover lumbar artificial disc replacementIndicationINDICATIONS FOR LUMBAR SURGERY: (This section of the clinical guidelines can be found on theNIA Magellan Clinical website, which thoroughly provides the clinical criteria for each of the lumbar andpre-sacral spine surgery categories.)I.Indications for Lumbar Discectomy/Microdiscectomy: Surgical indications for intervertebral discherniation:II.Indications for Lumbar Decompression: Laminectomy, Laminotomy, Facetectomy, andForaminotomy. These procedures allow decompression by partial or total removal of variousparts of vertebral bone and ligaments. Surgical Indications for spinal canal decompression dueto lumbar spinal stenosis:III.Indications for Lumbar Spine Fusion:IV.CONTRAINDICATIONS FOR SPINE SURGERY (Note:Cases will not be approved if the belowcontraindications exist):1.2.3.4.V.ExclusionMedical contraindicationsPsychosocial risk factors.Active Tobacco or NicotineMorbid ObesityOther ADDITIONAL INFORMATIONServices not covered: The following procedures are not covered as they are either still underinvestigation or are not recommended based upon the current evidence: Percutaneous Lumbar DiscectomyLaser DiscectomyPercutaneous Radiofrequency Disc DecompressionIntradiscal Electrothermal Annuloplasty (IDEA or IDET)Nucleus Pulpous ReplacementPre-Sacral Fusion, orLumbar Artificial Disc ReplacementCODINGThe coding listed in this medical policy is for reference only. Covered and non-covered codes are within this list.CPT CodeLumbar Spinal Fusion (single level) Surgery22533Arthrodesis, lateral extracavitary technique, including minimal discectomy toprepare interspace; lumbar22558Arthrodesis, anterior interbody technique, including minimal discectomy toprepare interspace; (other than for decompression); lumbar22612Arthrodesis, posterior or posterolateral technique, single level; lumbar (withlateral transverse technique, when performed)22630Arthrodesis, posterior interbody technique, including laminectomy and/ordiscectomy to prepare interspace, single interspace; lumbarNot every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule ofBenefits to determine coverage [MPMPPC051001].2
CPT Code22633Lumbar Spinal Fusion (single level) SurgeryArthrodesis, combined posterior or posterolateral technique with posteriorinterbody technique including laminectomy and/or discectomy sufficient toprepare interspace, single interspace and segment; lumbarFor CPT codes listed above include also Decompression (see below for codes)CPT CodeLumbar Spinal Fusion (multiple levels) Surgery22533Arthrodesis, lateral extracavitary technique, including minimal discectomy toprepare interspace; lumbar 22534Arthrodesis, lateral extracavitary technique, including minimal discectomy toprepare interspace; thoracic or lumbar, each additional vertebral segment22558Arthrodesis, anterior interbody technique, including minimal discectomy toprepare interspace; lumbar 22585Arthrodesis, anterior interbody technique, including minimal discectomy toprepare interspace; each additional interspace. (List separately in addition tocode for primary procedure) Code first (22554-22558)22612Arthrodesis, posterior or posterolateral technique, single level; lumbar 22614Arthrodesis, posterior or posterolateral technique, single level; each additionalvertebral segment. (List separately in addition to code for primary procedure)Code first (22612, 22630,22633)22630Arthrodesis, posterior interbody technique, including laminectomy and/ordiscectomy to prepare interspace, single interspace; lumbar 2263222633 22634Arthrodesis, posterior interbody technique, including laminectomy and/ordiscectomy to prepare interspace, single interspace; each additionalinterspace. (List separately in addition to code for primary procedure). Codefirst (22612, 22630, 22633)Arthrodesis, combined posterior or posterolateral technique with posteriorinterbody technique including laminectomy and/or discectomy sufficient toprepare interspace, single interspace and segment; lumbarArthrodesis, combined posterior or posterolateral technique with posteriorinterbody technique including laminectomy and/or discectomy sufficient toprepare interspace, single interspace and segment; each additional interspaceand segment. (List separately in addition to code for primary procedure). Codefirst (22633)For CPT codes listed above include also Decompression (see below for codes)CPT Code63005630126301763030 63035Lumbar Decompression ProceduresLaminectomy with exploration and/or decompression of spinal cord and/orcauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinalstenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis.Laminectomy with removal of abnormal facets and/or pars inter-articularis withdecompression of cauda equina and nerve roots for spondylolisthesis, lumbar(Gill type procedure)Laminectomy with exploration and/or decompression of spinal cord and/orcauda equina, without facetectomy, foraminotomy or discectomy, more than 2vertebral segments; lumbarLaminotomy, with decompression of nerve root(s), including partialfacetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1interspace, lumbarLaminotomy, with decompression of nerve root(s), including partialfacetectomy, foraminotomy and/or excision of herniated intervertebral disc;each additional interspace, cervical or lumbar. (List separately in addition tocode for primary procedure). Code first (63020-63030)Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule ofBenefits to determine coverage [MPMPPC051001].3
CPT CodeLumbar Decompression ProceduresLaminotomy, (hemilaminectomy) with decompression of nerve root(s),including partial facetectomy, foraminotomy and/or excision of herniatedintervertebral disc, reexploration, single interspace; lumbarLaminotomy, (hemilaminectomy) with decompression of nerve root(s),including partial facetectomy, foraminotomy and/or excision of herniatedintervertebral disc, reexploration, single interspace; each additional lumbarinterspace. (List separately in addition to code for primary procedure). Firstcode (63042)Laminectomy, facetectomy and foraminotomy, (unilateral or bilateral withdecompression of spinal cord, cauda equine and/or nerve root[s]. [e.g., spinalor lateral recess stenosis]), (single vertebral segment; lumbarLaminectomy, facetectomy and foraminotomy, (unilateral or bilateral withdecompression of spinal cord, cauda equine and/or nerve root[s]. [e.g., spinalor lateral recess stenosis]), (single vertebral segment; each additionalsegment, cervical, thoracic, or lumbar. (List separately in addition to code forprimary procedure). Code first (63045-63047).63042 6304463047 6304863056Transpedicular approach with decompression of spinal cord, equina and/ornerve root(s), single segment; lumbar. 63057Transpedicular approach with decompression of spinal cord, equina and/ornerve root(s), single segment; each additional segment, thoracic or lumbar.(List separately in addition to code for primary procedure). Code first (6305563056)Lumbar Discectomy/Microdiscectomy procedureCPT CodesLaminotomy, with decompression of nerve root(s), including partialfacetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1interspace, lumbarLaminotomy, with decompression of nerve root(s), including partialfacetectomy, foraminotomy and/or excision of herniated intervertebral disc;each additional interspace, cervical or lumbar. (List separately in addition tocode for primary procedure). Code first (63020-63030)Endoscopic decompression of spinal cord, nerve root(s), includinglaminotomy, partial facetectomy, foraminotomy, discectomy and/or excision ofherniated intervertebral disc, 1 interspace, lumbar.63030 6303562380Lumbar Artificial Disc ReplacementCPT Codes(not payable, considered investigational)22857Total disc arthroplasty, anterior approach, including discectomy to prepareinterspace, single interspace, lumbar22862Revision including replacement of total disc arthroplasty, anterior approach,single interspace; lumbar22865Removal of total disc arthroplasty, anterior approach, single interspace;lumbar0163T, 0164T and 0165TAdd-on codes for the above procedures are also non covered.CERVICAL SPINAL SURGERYCervical Spine Surgery1.2.3.4.5.6.7.Anterior Cervical Decompression with Fusion - Single Level (ACDF)Anterior Cervical Decompression with Fusion - Multiple Level (ACDF)Cervical Posterior Decompression with Fusion - Multiple LevelsCervical Posterior Decompression with Fusion - Single LevelCervical Artificial Disc - Single LevelCervical Artificial Disc - Two LevelsCervical Posterior Decompression (without fusion)Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule ofBenefits to determine coverage [MPMPPC051001].4
8.DescriptionCervical Anterior Decompression (without fusion)This guideline outlines the key surgical treatments and indications for common cervicalspinal 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 clinicalindications by surgical type. Operative treatment is indicated only when the natural historyof an operatively treatable problem is better than the natural history of the problem withoutoperative treatment. Choice of surgical approach is based on anatomy, the patient'spathology, and the surgeon's experience and preference. All operative interventions mustbe based on a positive correlation with clinical findings, the natural history of the disease,the clinical course, and diagnostic tests or imaging results.Artificial disc replacement is an alternative to spinal fusion for the treatment ofsymptomatic disc disease. These devices are designed to maintain the function of thenatural spine by preserving motion, and to potentially limit the incidence of adjacentsegment degeneration. Artificial disc replacements are available for the lumbar andcervical spine. Presbyterian Health Plan covers cervical artificial disc replacement,but does not cover lumbar artificial disc replacementIndicationsINDICATIONS FOR CERVICAL SURGERY: This section of the clinical guidelines can befound on the Magellan Clinical guideline, which thoroughly provides the clinical criteria forthe following:I.Anterior Cervical Decompression with Fusion (ACDF) - Single Level:II.Anterior Cervical Decompression with Fusion (ACDF) - Multiple Level:III.Cervical Posterior Decompression with Fusion - Single Level:IV.Cervical Posterior Decompression with Fusion - Multiple Levels:V.Cervical Posterior Decompression (w/o fusion):VI.Cervical Artificial Disc Replacement (Single or Two Level)VII.Cervical Anterior Decompression (without fusion)VIII.CODINGThe coding listed in this medical policy is for reference only. Covered and non-covered codes are within this list.CPT CodesAnterior Cervical Decompression with Fusion (ACDF) Single levelArthrodesis, anterior transoral or extraoral technique, clivus-C1-C2, with or withoutexcision of odontoid processArthrodesis, anterior interbody, including disc space preparation, discectomy,22551osteophytectomy and decompression of spinal cord and/or nerve roots; cervicalbelow C2Arthrodesis, anterior interbody technique, including minimal discectomy to prepare22554interspace; cervical below C2Additional Procedures Codes: Vertebral Corpectomy: 63081, 63082, 63300, 63304, 63308 Decompression: 63075, 63076 Removal of Artificial Disc: 2286422548CPT CodesAnterior Cervical Decompression with Fusion (ACDF) – Multiple level:22548Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2, with or withoutexcision of odontoid process22551Arthrodesis, anterior interbody, including disc space preparation, discectomy,osteophytectomy and decompression of spinal cord and/or nerve roots; cervicalbelow C2Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule ofBenefits to determine coverage [MPMPPC051001].5
CPT CodesAnterior Cervical Decompression with Fusion (ACDF) – Multiple level: 22552Arthrodesis, anterior interbody, including disc space preparation, discectomy,osteophytectomy and decompression of spinal cord and/or nerve roots; cervicalbelow C2, each additional interspace. (List separately in addition to code for primaryprocedure). Code first (22551)22554Arthrodesis, anterior interbody technique, including minimal discectomy to prepareinterspace; cervical below C2 22585Arthrodesis, anterior interbody technique, including minimal discectomy to prepareinterspace; each additional interspace. (List separately in addition to code for primaryprocedure). Code first (22554).Additional Procedure Codes: Vertebral Corpectomy: 63081, 63082, 63300, 63304, 63308 Decompression: 63075, 63076 Removal of Artificial Disc: 22864CPT CodesCervical Posterior Decompression with Fusion – Single Level22590Arthrodesis, posterior technique, craniocervical22595Arthrodesis, posterior technique, atlas-axis22600Arthrodesis, posterior or posterolateral technique, single level; cervical below C2segmentAdditional Procedure Codes: Decompression: 63001, 63015, 63020, 63035, 63040, 63043, 63045, 63048, 63050, 63051CPT CodesCervical Posterior Decompression with Fusion- Multiple Levels:22590Arthrodesis, posterior technique, craniocervical22595Arthrodesis, posterior technique, atlas-axis22600Arthrodesis, posterior or posterolateral technique, single level; cervical below C2segment 22614Arthrodesis, posterior or posterolateral technique, single level; each additionalvertebral segment. (List separately in addition to code for primary procedure). Codefirst (22600)Additional Procedure Codes:Decompression: 63001, 63015, 63020, 63035, 63040, 63043, 63045, 63048, 63050, 63051 CPT CodeCervical Artificial Disc – Single Level:22856Total disc arthroplasty, anterior approach, including discectomy with end platepreparation; single interspace, cervical22861Revision including replacement of total disc arthroplasty, anterior approach, singleinterspace; cervical22864Removal of total disc arthroplasty, anterior approach, single interspace; cervicalCPT CodeCervical Artificial Disc – Two Levels:22856Total disc arthroplasty, anterior approach, including discectomy with end platepreparation; single interspace, cervical22858Total disc arthroplasty, anterior approach, including discectomy with end platepreparation; second level, cervicalNot every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule ofBenefits to determine coverage [MPMPPC051001].6
CPT CodeCervical Artificial Disc – Two Levels:22861Revision including replacement of total disc arthroplasty, anterior approach, singleinterspace; cervical22864Removal of total disc arthroplasty, anterior approach, single interspace; cervical 0098TRevision including replacement of total disc arthroplasty, anterior approach, eachadditional interspace, cervical 0095TRemoval of total disc arthroplasty, anterior approach, each additional interspace,cervicalCPT Code6300163015630206304063045Cervical Posterior Decompression (without fusion):Laminectomy with exploration and/or decompression of spinal cord and/or caudaequina, without facetectomy, foraminotomy or discectomy, 1 or 2 vertebral segments;cervicalLaminectomy with exploration and/or decompression of spinal cord and/or caudaequina, without facetectomy, foraminotomy or discectomy, more than 2 vertebralsegments; cervicalLaminotomy, with decompression of nerve root(s), including partial facetectomy,foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervicalLaminotomy, with decompression of nerve root(s), including partial facetectomy,foraminotomy and/or excision of herniated intervertebral disc, reexploration, singleinterspace; cervicalLaminectomy, facetectomy and foraminotomy, (unilateral or bilateral withdecompression of spinal cord, cauda equine and/or nerve root[s]. [e.g., spinal orlateral recess stenosis]), single vertebral segment; cervical63050Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebralsegments;63051Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebralsegments; with reconstruction of the posterior bony elements 63035 63043 63048CPT CodeLaminotomy, with decompression of nerve root(s), including partial facetectomy,foraminotomy and/or excision of herniated intervertebral disc; each additionalinterspace, cervical or lumbar (List separately in addition to code for primaryprocedure). Code first (63020-63030)Laminotomy, with decompression of nerve root(s), including partial facetectomy,foraminotomy and/or excision of herniated intervertebral disc, reexploration, singleinterspace; each additional cervical interspace. (List separately in addition to code forprimary procedure). Code first (63040)Laminectomy, facetectomy and foraminotomy, (unilateral or bilateral withdecompres
CODING The coding listed in this medical policy is for reference only. Covered and non-covered codes are within this list. CPT Code Lumbar Spinal Fusion (single level) Surgery . Spine surgery is a complex ar
