MEDICAL POLICY

POLICY
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SCOPE
BENEFIT APPLICATION
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REFERENCES
CODING
APPENDIX
HISTORY

Lumbar Fusion

Number 7.01.542

Effective Date April 8, 2013

Revision Date(s) 04/08/13; 10/09/12; 09/11/12

Replaces N/A

Policy

Lumbar Fusion – Covered Conditions

An elective lumbar fusion performed for any of the following conditions may be considered medically necessary:

  • Spondylolisthesis with at least 4 mm of segmental instability in the sagittal plane measured on functional flexion and extension views on upright x-ray with:
  • Persistent back pain, or radicular symptoms, and ongoing symptoms that decrease function.
  • Acute Spinal fracture with instability or neurologic compression confirmed by imaging studies (e.g., MRI, CT or x-rays);
  • Instability caused by previous lumbar decompression, vertebral tumor or vertebral infection confirmed by imaging studies (e.g., MRI, CT or x-rays);
  • Spinal stenosis with persistent LBP and decrease in function confirmed by imaging studies (e.g., MRI, CT, or x-rays) and one of the following:
  • Segmental instability manifested by 4 mm of instability in the sagittal plane measured on functional flexion and extension views on upright x-ray, in the same area as decompression is needed;
  • Degenerative instability (e.g. scoliosis or spondylolisthesis) in the same area as decompression is needed;
  • Where facet joints excision exceed 50% bilaterally or complete excision of one facet is performed.
  • Pseudoarthrosis, confirmed by radiological evidence of instability with all of the following:
  • Lucency around the hardware per x-ray, MRI or CT scan; and
  • More than 4 mm of segmental instability; and
  • Persistent LBP or radicular symptoms decrease in function.
  • Scoliosis with Cobb Angle >40 degrees; and
  • Persistent axial pain; or
  • Neurogenic symptoms; and
  • Impaired function or loss of function.
  • Adjacent segment breakdown with 4 mm of segmental instability and/or symptomatic stenosis; (developing at least 6 months after a prior fusion)
  • Flat back syndrome with truncal imbalance. (See Policy Guidelines)

Lumbar Fusion – Excluded Conditions

A lumbar fusion performed for any condition not listed above, including non-radicular pain with common degenerative changes (degenerative disc disease, facet joint arthrosis, etc.) or post-laminectomy low back pain is considered not medically necessary.

Requests for multi-level fusions of 3 or more fusion levels must be reviewed by a medical director.

Related Policies

7.01.85

Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures

7.01.87

Artificial Intervertebral Disc: Lumbar Spine

7.01.130

Axial Lumbosacral Interbody Fusion

7.01.138

Interspinous Fixation (Fusion) Devices

7.01.537

Artificial Intervertebral Disc: Cervical Spine

7.01.551

Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy, Laminectomy

Policy Guidelines

Definitions of terms used in this policy:

Axial Pain is non-specific low back pain, which is non-radiating to the buttocks, legs or feet.

Cobb Angle is a measurement of the degree of side-to-side spinal curvature, in scoliosis.

Flatback Syndrome occurs when there is a loss either of lordosis or kyphosis or both, making the spine straight. Persons may appear stooped forward and often have difficulty standing up straight.

Truncal imbalance is an imbalance in trunk muscle strength, i.e., there is lower extensor muscle strength than flexor muscle strength.

Instability refers to abnormal or excessive motion between two or more vertebrae. This may be a source of pain or may cause irritation to adjacent nerves. (5)

Spondylolisthesis is a spinal condition whereby one of the vertebra slips forward or backward on an adjacent vertebra.

Description

Back pain is a common medical problem that may affect 8 out of 10 people at some point in their lives. Back pain is called chronic if it lasts more than three months. (1). Age-related disc degeneration, facet joint arthrosis and segmental instability are leading factors causing chronic back pain. (2). Back pain in the vast majority of patients (about 90%) improves over 2 months with minimal intervention. The smaller number of patients who develop chronic spine pain utilize more than the majority of health resources expended on this expensive medical problem. (16)

The most common symptoms of spinal disorders are regional pain and decreased range of motion associated in a minority of patients with radiating pain. For the majority of patients, pain has mechanical characteristics: Its intensity increases with physical activity, movements, or some postures and decreases with rest. However, it has been demonstrated that nocturnal pain is not uncommon in the absence of serious specific spinal disorders. The precise topography of pain is often difficult for the patient to describe, and its interpretation is difficult owing to the overlap of the cutaneous projections between adjacent spinal levels and the similarities between dermatomes, myotomes, and sclerotomes.(16) Lumbar fusion (also known as lumbar arthrodesis) is a surgical procedure that can stabilize the spine by fusing together two or more vertebrae, using a variety of methods, with or without instrumentation (screws, rods, cages, etc.) A spinal fusion eliminates motion between vertebral segments.

Deyo et al. report, “The use of spinal fusion surgery in the United States is rapidly increasing. National survey data indicate that the annual number of spinal fusion operations rose by 77% between 1996 and 2001.” (3) They mention that this increase may be the result of technological advances such as bone morphogenetic protein, fusion cage implants, financial incentives, and additional unclear indications for surgery such as discogenic back pain.

When diagnostic testing (which may include plain radiographs with flexion and extension views, magnetic resonance imaging (MRI), computed tomography (CT) scans, and myelograms) does not clearly identify a serious condition such as a fracture or spondylolisthesis (see Policy statement for other indications), treatment with non-surgical care is appropriate. Indications for lumbar fusion in this policy require a mechanical spinal problem such as a traumatic injury or other spinal deformity. Degenerative disc disease is considered to be a normal part of aging and treatment for this type of disc problem is non-surgical care.

According to AAOS Guidelines for Spinal Fusion a pre-surgical orthopedic evaluation includes four components (4):

  • A medical history that includes an assessment of duration, pattern and intensity of back pain, current medications including corticosteroid use, social/work/leisure activities, and what increases and decreases pain.
  • A physical examination to assess the stability, strength, alignment and motion of the spine, as well as a neurologic evaluation.
  • Diagnostic tests – X-rays which may be obtained to evaluate the bones and structure of spine; an MRI may be obtained to provide more detailed information about the spine. A myelogram may be obtained to define bony and soft tissue structures affecting the nerve root. Other imaging studies such as CT may also be obtained to provide details about the bones and soft tissues not seen on regular X-rays.
  • Discussion with the patient by the physician of the findings of the physical examination and diagnostic evaluation and the treatment options (which might not include surgery). Initially, medication and physical therapy may be prescribed to reduce inflammation at the site of the pain and to strengthen the muscles supporting the spinal column.

Note: Chronic low back pain often improves on its own over time or with the help of non-surgical care.

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

N/A

Rationale

Lumbar Fusion

Brox and colleagues (8) compared the effectiveness of lumbar fusion with cognitive intervention and exercises in 64 patients with chronic low back pain and disc degeneration. The main outcome measure was the Oswestry Disability Index (ODI). At the one-year follow-up visit, 97% of the patients were examined. The ODI was reduced from 41 to 26 after surgery, compared with 42 to 30 after cognitive intervention and exercises. Improvements in back pain, analgesic use, emotional distress, life satisfaction and return to work were not different. Fear avoidance beliefs and fingertip-floor distance were reduced more after non-operative treatment. Lower limb pain was reduced more after surgery. The main outcome measure showed equal improvement in patients with chronic low back pain and disc degeneration when randomized to surgery (lumbar fusion) or to cognitive behavioral therapy and exercises.

Fritzell and colleagues (9) studied patients to determine whether lumbar fusion could reduce pain and disability more effectively when compared with nonsurgical treatment. The surgical procedure included three different fusion techniques. The nonsurgical treatment involved different kinds of treatment that was unstructured and included physical therapy, acupuncture, injections, and cognitive training. This randomized controlled study had a two-year follow-up performed by an independent observer. Their results show at the two-year follow-up 289 of 294 patients had reduced back pain in the surgical group by 33% (64 to 43 measured by the VAS) while the nonsurgical group decreased by 7% (63 to 58). Pain improved most during the first 6 months. Disability according to Oswestry was reduced by 25 % (47 to 36) compared with 6% (48 to 46) among nonsurgical patients. The depression symptoms, according to Zung, were reduced by 20% in the surgical group compared with 7% in the nonsurgical group. In the surgical group only 63% rated themselves as “much better” or “better” compared with 29% in the nonsurgical group. The “net back to work rate” was in favor of surgical treatment (36% vs. 13%). The authors concluded that lumbar fusion could diminish pain and decrease disability more efficiently than commonly used nonsurgical treatment. Critics of the Swedish study suggest that the benefit from fusion was small: pain and functioning improved by about 30 per cent, and only one in six patients became free of pain. Additionally, they point out that the trial was not blinded and the conservative care may not have represented optimal non-surgical care.

Brox and colleagues (13) report on their study comparing the effectiveness of lumbar fusion with cognitive intervention and exercises. Sixty patients aged 25-60 years with low back pain lasting longer than 1 year after surgery for disc herniation were randomly assigned to the two treatment groups. Cognitive intervention consisted of a lecture intended to provide an understanding that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it. This was reinforced by three daily physical exercises sessions for 3 weeks. Ninety-seven percent of the patients completed 1-year follow-up. The Oswestry Disability Index was improved from 47 to 38 after fusion and from 45 to 32 after cognitive intervention and exercises. The success rate was 50% in the fusion group and 48% in the cognitive intervention/exercise group. The authors concluded that the lumbar fusion group failed to show any benefit over the cognitive intervention/exercise group.

Nguyen and colleagues (14) studied a historical cohort of 725 workers’ compensation (WC) cases who had lumbar fusions and compared them to 725 controls who were randomly selected from a pool of WC subjects with chronic low back pain diagnoses. Main outcomes were reported as Return To Work (RTW) status 2 years after the date of injury (for controls) or 2 years after the date of surgery (for cases). Workers’ compensation cases with lumbar fusions had a poorer RTW status 2 years after surgery (reported to be 27% vs. 67% in nonsurgical patients), higher disability status (reported to be 11% for surgical cases vs. 2% for nonsurgical patients), and a larger number of subjects continued on daily opioids (Morphine) compared to nonsurgical controls. The greater the daily total amount of opioids, the less likely it was for a worker to RTW. Significant predictors of RTW status for surgical cases were the number of days off and total Morphine usage. Number of days off and weekly wages were the only significant predictors of RTW status for nonsurgical controls.

Carreon and colleagues (15) compared clinical outcomes after lumbar fusion in patients receiving workers’ compensation with a case-matched control group who were not on workers’ compensation. The mean 2-year Oswestry Disability Index (ODI), Short Form – 36 Physical Component Summary, and back and leg pain scores were significantly lower in the workers compensation patients. Only 19% of workers’ compensation patients achieved minimum clinically important difference in terms of ODI compared with 36% of those not receiving workers’ compensation. Only 16% of workers’ compensation patients achieve SF-36 minimum clinically important difference compared with 40% of those not receiving workers’ compensation. The improvement in back pain was similar between the two groups, but patients on workers’ compensation remained more disabled after lumbar fusion.

Chou and colleagues (10) reported on a systematic review (2009) that assessed benefits and harms of surgery for nonradicular back pain with degenerative changes. The results showed that for nonradicular low back pain with common degenerative changes, there was fair evidence from randomized trials that fusion is no better than intensive rehabilitation with a cognitive behavioral emphasis for improvement in pain or function, but slightly to moderately superior to standard nonsurgical therapy. Additionally, they report, “less than half of patients experience optimal outcomes (defined as no more than sporadic pain, slight restriction of function, and occasional analgesics) following fusion.”

Mirza and Deyo (7) performed a systematic review of randomized trials comparing lumbar fusion surgery to non-surgical treatment of chronic back pain associated with lumbar disc degeneration. Based on four trials that focused on non-specific chronic back (discogenic back pain), the studies enrolled similar participants focusing on patients with back pain of duration more than one year and no other specific etiology for the pain other than disc degeneration. The non-surgical treatment involved a program of education, cognitive therapy and exercise (physical therapy) in three studies. Another study included unstructured therapy. The results of these comparisons were not consistent. One study suggested greater improvement in disability following fusion compared to unstructured non-operative care at two years. Three trials suggested no substantial difference in disability scores at one year and two years when fusion was compared to a three-week cognitive behavior treatment addressing fears about back injury. However, two of these trials were underpowered to identify clinical differences. Another trial had high rates of cross-over (20%) and loss to follow-up (20%). The authors concluded that surgery may be more efficacious than unstructured nonsurgical care but may not be more efficacious when there is structured cognitive behavior therapy. However, they also state “methodological limitations of the randomized trials prevent firm conclusions.”

Summary

Literature suggests that the first line of treatment for chronic lumbar pain is a comprehensive structured multidisciplinary non-surgical approach. There are some select patients (e.g. those patients with DDD and others with non-structural causes of back pain) that may require a longer period of non-surgical care. A lumbar fusion may be a consideration ONLY when there is a structural problem.

2012 Update

A literature search of the MEDLINE database conducted from September 2011 through August 2012 did not identify any new studies that compare lumbar fusion surgery to non-surgical treatment of back pain.

Leone and colleagues (18) Intervertebral instability of the lumbar spine is thought to be a possible pathomechanical mechanism underlying low back pain and sciatica and is often an important factor in determining surgical indication for spinal fusion and decompression. Instability of the lumbar spine, however, remains a controversial and poorly understood topic. At present, much controversy exists regarding the proper definition of the condition, the best diagnostic methods, and the most efficacious treatment approaches. Clinical presentation is not specific, and the relationship between radiologic evidence of instability and its symptoms is controversial. Because of its simplicity, low expense, and pervasive availability, functional flexion-extension radiography is the most thoroughly studied and the most widely used method in the imaging diagnosis of lumbar intervertebral instability.

References

  1. Medline Plus (A service of the US National Library of Medicine and the National Institutes of Health). A Description of Back Pain. Last accessed January 22, 2013.
  2. Kwon BK, Vaccaro AR, Grauer JN, Beiner J. Indications, techniques, and outcomes of posterior surgery for chronic low back pain. Orthop Clin North Am. 2003;34(2):297-308.
  3. Deyo RA, Nachermson A, Mirza SK. Spinal Fusion Surgery – The case for Restraint. N Engl J Med 2004;350(7):722-726.
  4. American Academy of Orthopedic Surgeons. AAOS Guidelines for Spinal Fusion. Last reviewed and updated: June 2010. Last accessed January 22, 2013.
  5. North American Spine Society. A Fair and Balanced View of Spine Fusion Surgery. [press release] Burr Ridge, IL: NASS; July 25, 2004. Last accessed January 22, 2013.
  6. American Academy of Orthopedic Surgeons. AAOS Guidelines for Low Back Pain. Last reviewed and updated: May 2009. Last accessed January 22, 2013.
  7. Mirza, SK, Deyo RA. Systematic Review of Randomized Trials Comparing Lumbar Fusion Surgery to Nonoperative Care for Treatment of Chronic Back Pain. Spine 2007;32(7): 816-823.
  8. Brox JI, Sorensen R, Friis A et.al. Randomized Clinical Trial of Lumbar Instrumented Fusion and Cognitive Intervention and Exercises in Patients with Chronic Low Back Pain and Disc Degeneration. Spine 2003;28(17);1913-1921.
  9. Fritzell P, Hagg, O, Wessberg P et.al. 2001 Volvo Award Winner in Clinical Studies: Lumbar Fusion versus Nonsurgical Treatment for Chronic Low Back Pain. Spine 2001;26(23); 2521-2534.
  10. Chou R, Loeser JD, Owens DK et al. American Pain Society Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine 2009;34(10):1066-1077.
  11. Technology Assessment on Lumbar Fusion by the Washington State Health Technology Assessment Program (2007). Lumbar Fusion. Last accessed January 22, 2013.
  12. Chou R, Baisden J, Carragee EJ et al. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine (Phila Pa 1976) 2009 May 1;34(10):1094-109.
  13. Brox JI, Reikeras O, Nygaard O et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain. 2006 May;122 (1-2):145-55.
  14. Nguyen TH, Randolph DC, Talmage J et al. Long-term Outcomes of Lumbar Fusion Among Workers’ Compensation Subjects An Historical Cohort Study. Spine (Phila PA 1976). 2011 Feb 15;36(4):320-31.
  15. Carreon LY, Glassman SD, Kantamneni NR et al. Clinical outcomes after posterolateral lumbar fusion in Workers’ Compensation Patients A Case-Control Study. Spine (Phila PA 1976). 2010 Sep 1;35(19):1812.
  16. Bope ET, and Kellerman RD: In: Conn’s Current Therapy 2012, 1st ed. Philadelphia, PA: Elsevier Saunders, 2011: 39-43. Chapter 1. http://www.mdconsult.com.proxy.heal-wa.org/books/page.do?eid=4-u1.0-B978-1-4557-0738-6..00001-2--sc0065&isbn=978-1-4557-0738-6&uniqId=358454974-2#4-u1.0-B978-1-4557-0738-6..00001-2--t0100 Last accessed Janaury 22, 2013.
  17. Lee JH, Hoslino Y, et al. Trunk muscle weakness as a risk factor for low back pain. A 5 year prospective study. Spine (Phila Pa 1976), 1999 Jan 1;24(1):54-7.
  18. Leone A, Guglielmi G, et al. Lumbar Intervertebral Instability: A Review. Radiology 2007; Oct. (245): 62-77. Available online at: http://radiology.rsna.org/content/245/1/62.long#abstract-1. Last accessed Janaury 22, 2013.

Coding

Codes

Number

Description

CPT

0309T

Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (List separately in addition to code for primary procedure) (new code 1/1/13)

 

22533

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

 

22534

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression; thoracic or lumbar, each additional vertebral segment

 

22558

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

 

22585

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)

 

22586

Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace (effective 1/1/13)

 

22612

Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique)

 

22614

Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)

 

22630

Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar

 

22632

Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure)

 

22633

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar

 

22634

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure)

 

22800

Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments

 

22802

Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments

 

22804

Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments

 

22808

Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments

 

22810

Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments

 

22812

Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments

 

22840

Posterior non-segmental instrumentation (e.g., Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)

 

22842

Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)

 

22843

Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure)

 

22844

Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure)

 

22845

Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)

 

22846

Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure)

 

22847

Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure)

 

22851

Application of intervertebral biomechanical device(s) (e.g., synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure)

 

62290

Injection procedure for discography, each level; lumbar

 

63030

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches; 1 interspace, lumbar

 

72295

Discography, lumbar, radiological supervision and interpretation

ICD-9 Procedure

81.06

Lumbar and lumbosacral fusion, anterior technique

 

81.07

Lumbar and lumbosacral fusion, lateral transverse process technique

 

81.08

Lumbar and lumbosacral fusion, posterior technique

ICD-9 Diagnosis

722.52

Degeneration of lumbar or lumbosacral intervertebral disc

 

722.73

Intervertebral lumbar disc disorder with myelopathy, lumbar region

 

722.83

Postlaminectomy syndrome, lumbar region

 

724.02

Spinal stenosis of lumbar region

 

724.2

Lumbago

 

724.3

Sciatica

 

724.4

Thoracic or lumbosacral neuritis or radiculitis, unspecified

 

724.5

Backache, unspecified

 

729.2

Neuralgia, neuritis, and radiculitis, unspecified

 

733.81

Malunion of fracture

 

733.82

Nonunion of fracture

 

737.30

Scoliosis [and kyphoscoliosis], idiopathic

 

737.43

Scoliosis associated with other condition

 

738.4

Acquired spondylolisthesis

 

756.12

Congenital spondylolisthesis

 

806.4

Closed fracture of lumbar spine with spinal cord injury

 

806.5

Open fracture of lumbar spine with spinal cord injury

HCPCS

   

Type of Service

Surgery

 

Place of Service

Inpatient

 

Appendix

N/A

History

Date

Reason

03/08/11

Add to Surgery Section - New Policy held for provider notification. The effective and publication date will be 9/1/2011.

05/18/11

Policy Published - The policy was published on the internal and external sites with an effective date of September 1, 2011.

12/2/11

Related Policies updated; 7.01.115 removed.

01/11/12

Codes 22633 and 22634 added.

09/11/12

Replace policy - Policy statements extensively revised for clarification. Instability clarified by adding 4 mm of translational instability. Spinal stenosis criteria clarified. Pseudoarthrosis criteria clarified by adding lucency around the hardware per x-ray or CT scan. Failure of 6 months of nonsurgical care removed from all policy statements. Added reference 16.

10/09/12

Replace policy - Added definitions for truncal imbalance. Added clarity to spondylolisthesis statement – It is measured in the saggital plane on functional flexion and extension views on upright x-ray. MRI and CT removed from bullet. Added references 17 and 18.

12/19/12

Update Related Policies – Add 7.01.85.

01/10/13

Coding update. CPT codes 22586 and 0309T, effective 1/1/13, added to policy.

04/08/13

Clarification only. “Acute” added to describe spinal fracture within the Policy section. Literature reviewed.

12/06/13

Update Related Policies. Add 7.01.138.

01/21/14

Update Related Policies. Add 7.01.551.

01/30/14

Update Related Policies. Add 7.01.130.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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