Cervical and Lumbar Spinal Procedures, MPM 25

Subject: Cervical and Lumbar Spinal Procedures Medical Policy #: 25.1 Status: Reviewed

Medical Policy

Original Effective Date: 05/17/2010 Last Review Date: 05/25/2022

Disclaimer

Refer to the member's specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans or the plan may have broader or more limited benefits than those listed in this Medical Policy.

Coverage Determination

Prior Authorization is required, Log on to the NIA Magellan website: to submit a "Request an Exam". For spinal surgery of the lumbar and cervical, Presbyterian uses NIA Magellan. NIA prior authorizes or manage the provider precertification for Musculoskeletal Surgery Services, and not the facility precertification. Musculoskeletal Surgery Services rendered through the Emergency Room are not managed by NIA. All other inpatient and outpatient Musculoskeletal surgery procedures are managed by NIA for the surgeries outlined below. See also Investigative List and New Technology Assessment (Non-covered Services), MPM 36.0 for Lumbar Artificial Disk Replacement (LADR).

LUMBAR SPINAL SURGERY

Indication

INDICATIONS FOR SURGERY: (This section of the clinical guidelines can be found on the NIA Magellan Clinical website, which thoroughly provides the clinical criteria for each of the lumbar and presacral spine surgery categories.)

? Lumbar Discectomy/Microdiscectomy ? Lumbar Decompression ? Lumbar Spine Fusion single level ? Lumbar Fusion, Multiple levels

Exclusion

Services not covered: The following procedures are not covered as they are either still under investigation or are not recommended based upon the current evidence:

? Percutaneous Lumbar Discectomy ? Laser Discectomy ? Percutaneous Radiofrequency Disc Decompression ? Intradiscal Electrothermal Annuloplasty (IDEA or IDET) ? Nucleus Pulpous Replacement ? Pre-Sacral Fusion

CODING

The coding listed in this medical policy is for reference only. Covered and non-covered codes are within this list.

CPT Code 22533 22558 22612 22630

Lumbar Spinal Fusion (single level) Surgery

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace; lumbar Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace; (other than for decompression); lumbar Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace, single interspace; lumbar

Not every Presbyterian health plan contains the same benefits. Please refer to the member's specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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CPT Code 22633 63052

63053

CPT Code 22534 22585 22614 22632 22634

63052

63053

CPT Code 63005 63012 63017 63042 63044 63047

63048

Lumbar Spinal Fusion (single level) Surgery

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace, single interspace and segment; lumbar Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure) Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; each additional segment (List separately in addition to code for primary procedure)

Lumbar Spinal Fusion (multiple levels) Surgery

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace; thoracic or lumbar, each additional vertebral segment Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace; each additional interspace. (List separately in addition to code for primary procedure) Code first (22554-22558) Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment. (List separately in addition to code for primary procedure) Code first (22612, 22630,22633) Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace, single interspace; each additional interspace. (List separately in addition to code for primary procedure). Code first (22612, 22630, 22633) Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace, single interspace and segment; each additional interspace and segment. (List separately in addition to code for primary procedure). Code first (22633) Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure) Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; each additional segment (List separately in addition to code for primary procedure)

Lumbar Decompression Procedures

Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis. Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, more than 2 vertebral segments; lumbar Laminotomy, (hemilaminectomy) with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar Laminotomy, (hemilaminectomy) with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace. (List separately in addition to code for primary procedure). First code (63042) Laminectomy, facetectomy and foraminotomy, (unilateral or bilateral with decompression of spinal cord, cauda equine and/or nerve root[s]. [e.g., spinal or lateral recess stenosis]), (single vertebral segment; lumbar Laminectomy, facetectomy and foraminotomy, (unilateral or bilateral with decompression of spinal cord, cauda equine and/or nerve root[s]. [e.g., spinal or lateral recess stenosis]), (single vertebral segment; each additional segment, cervical, thoracic, or lumbar. (List separately in addition to code for primary procedure). Code first (63045-63047).

Not every Presbyterian health plan contains the same benefits. Please refer to the member's specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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CPT Code 63056 63057

CPT Codes 63030 63035

62380

Lumbar Decompression Procedures

Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s), single segment; lumbar. Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s), single segment; each additional segment, thoracic or lumbar. (List separately in addition to code for primary procedure). Code first (63055-63056)

Lumbar Discectomy/Microdiscectomy procedure

Laminotomy, with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar Laminotomy, with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar. (List separately in addition to code for primary procedure). Code first (63020-63030) Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar.

CERVICAL SPINAL SURGERY

Indications

INDICATIONS FOR CERVICAL SURGERY: This section of the clinical guidelines can be found on the Magellan Clinical guideline, which thoroughly provides the clinical criteria for the following:

?

Anterior Cervical Decompression with Fusion (ACDF) - Single Level:

?

Anterior Cervical Decompression with Fusion (ACDF) - Multiple Level:

?

Cervical Posterior Decompression with Fusion - Single Level:

?

Cervical Posterior Decompression with Fusion - Multiple Levels:

?

Cervical Posterior Decompression (w/o fusion):

?

Cervical Artificial Disc Replacement (Single or Two Level)

?

Cervical Anterior Decompression (without fusion)

CODING

The coding listed in this medical policy is for reference only. Covered and non-covered codes are within this list.

CPT Codes

Anterior Cervical Decompression with Fusion (ACDF) Single level

22548 22551 22554

Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2, with or without excision of odontoid process Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace; cervical below C2

CPT Codes 22548 22551

22552 22554

Anterior Cervical Decompression with Fusion (ACDF) ? Multiple level: Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2, with or without excision of odontoid process Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace. (List separately in addition to code for primary procedure). Code first (22551) Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace; cervical below C2

Not every Presbyterian health plan contains the same benefits. Please refer to the member's specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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CPT Codes 22585

CPT Codes 22590 22595 22600

CPT Codes 22590 22595 22600

22614

CPT Code 22856 22861 22864

CPT Code 22856 22858 22861 22864 0098T 0095T

CPT Code 63001

63015

63020

63040

63045

63050 63051

63035

63043

Anterior Cervical Decompression with Fusion (ACDF) ? Multiple level: Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace; each additional interspace. (List separately in addition to code for primary procedure). Code first (22554).

Cervical Posterior Decompression with Fusion ? Single Level Arthrodesis, posterior technique, craniocervical Arthrodesis, posterior technique, atlas-axis Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment

Cervical Posterior Decompression with Fusion- Multiple Levels: Arthrodesis, posterior technique, craniocervical Arthrodesis, posterior technique, atlas-axis Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment. (List separately in addition to code for primary procedure). Code first (22600)

Cervical Artificial Disc ? Single Level: Total disc arthroplasty, anterior approach, including discectomy with end plate preparation; single interspace, cervical Revision including replacement of total disc arthroplasty, anterior approach, single interspace; cervical Removal of total disc arthroplasty, anterior approach, single interspace; cervical

Cervical Artificial Disc ? Two Levels: Total disc arthroplasty, anterior approach, including discectomy with end plate preparation; single interspace, cervical Total disc arthroplasty, anterior approach, including discectomy with end plate preparation; second level, cervical Revision including replacement of total disc arthroplasty, anterior approach, single interspace; cervical Removal of total disc arthroplasty, anterior approach, single interspace; cervical Revision including replacement of total disc arthroplasty, anterior approach, each additional interspace, cervical Removal of total disc arthroplasty, anterior approach, each additional interspace, cervical

Cervical Posterior Decompression (without fusion): Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, 1 or 2 vertebral segments; cervical Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, more than 2 vertebral segments; cervical Laminotomy, with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical Laminotomy, with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical Laminectomy, facetectomy and foraminotomy, (unilateral or bilateral with decompression of spinal cord, cauda equine and/or nerve root[s]. [e.g., spinal or lateral recess stenosis]), single vertebral segment; cervical Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements Laminotomy, with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure). Code first (63020-63030) Laminotomy, with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single

Not every Presbyterian health plan contains the same benefits. Please refer to the member's specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

4

CPT Code

+63048

CPT Code 63075 +63076

CPT Code 63081 63082 63300 63304 63308

Cervical Posterior Decompression (without fusion): interspace; each additional cervical interspace. (List separately in addition to code for primary procedure). Code first (63040) Laminectomy, facetectomy and foraminotomy, (unilateral or bilateral with decompression of spinal cord, cauda equine and/or nerve root[s]. [e.g., spinal or lateral recess stenosis]), (single vertebral segment; each additional segment, cervical, thoracic, or lumbar (Code first (63045-63047). (List separately in addition to code for primary procedure)

Cervical Anterior Decompression (without fusion): Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace. (List separately in addition to code for primary procedure) Code first (63075).

Other codes that may apply to cervical surgery:

Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for primary procedure) Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, cervical Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, cervical Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; each additional segment (List separately in addition to codes for single segment)

Reviewed by / Approval Signatures

Clinical Quality & Utilization Mgmt. Committee: Gray Clarke MD Senior Medical Director: David Yu MD Date Approved: 05/25/2022

References

1. NIA Magellan, Lumbar Spinal Fusion Surgery, Lumbar Decompression Procedures, Lumbar Microdisectomy Only Procedure, ?2019-2021 National Imaging Associates, Inc., Guideline Number: NIA_CG_304, last revised date: Jan 2022. [Accessed 04/15/2022

2. NIA Magellan Healthcare, Presbyterian Health Plan Utilization Review Matrix 2022, Musculoskeletal Surgery (spine) [Cited 04/15/2022]

3. NIA Magellan, CERVICAL SPINE SURGERY, Guideline Number: NIA_CG_307, last revised date: June 2021. Accessed 04/15/2022

Publication History

07-27.16: 01-24-18: 09-26-18:

01-22-10: 05-22-20:

05-26-21:

Annual Review. Change to NIA Magellan Lumbar Spine Surgery criteria available on the RAD MD website Annual Review. See NIA Magellan criteria on RAD MD website The following Medical Policies were merged into this policy: ? Artificial Disc Replacement MPM 1.3 ? Lumbar Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy, MPM 12.0 ? Lumbar Fusion (Arthrodesis), MPM 12.1 Annual Review. No change to content. Web links updated. CQUMC approved NIA Magellan criteria July 31, 2019 Review the annual renewal of 2020-2021 NIA Magellan clinical guidelines used for Musculoskeletal Program. The changes go into effect on July 1, 2020. Medical Policy Committee found no changes to the agreed upon procedures Annual review. Reviewed by PHP Medical Policy Committee on 05/05/2021. No criteria change, will resume purchased criteria for NIA approved by CQUMC on 03/24/21. The NIA Magellan clinical guidelines and PHP/NIA Magellan Matrix) were reviewed and the following CPT codes were updated: Remove language in the PA "deny codes: 22858 and 0098T (Cervical Artificial Disc - Two Levels) as `investigational' in the PA grid". These codes are on the Matrix as covered and is also listed in the clinical guideline of NIA Magellan. Delete/remove 0375T from PA, since AMA deleted the code on 01/01/2020. New CPT codes added to

Not every Presbyterian health plan contains the same benefits. Please refer to the member's specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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05-25-22

policy: Vertebral Corpectomy: 63081, +63082, 63300, 63304, +63308. Non-covered LADR (including revision) codes 22857, 22862, 22865 and its related add-on codes 0163T, 0634T and 0165T are considered investigational for all LOB and will be configured to not pay and place these codes in the Investigational List MPM 36.0. Annual review. Reviewed by PHP Medical Policy Committee on 04-15-2022. Continue purchase criteria approved March 2022 for NIA Magellan 2022. The NIA Magellan clinical guidelines and PHP/NIA Magellan Matrix) were reviewed and the following CPT codes were added: 63052 and 63053, which will be added to require prior auth. PA grid says to deny codes 22858, 0375T 0098T as investigational. NIA lists both 22858 and 0098T as codes to be reviewed and does not mention it is non-covered or investigational. Remove 0375T from PA, since AMA deleted the code on 01/01/2020. Removed investigative codes (22857, 22862, 22865, 0163T, 0164T and 0165T) from policy since they are listed in the Investigative List, MPM 36.0

This Medical Policy is intended to represent clinical guidelines describing medical appropriateness and is developed to assist Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) Health Services staff and Presbyterian medical directors in determination of coverage. The Medical Policy is not a treatment guide and should not be used as such.

For those instances where a member does not meet the criteria described in these guidelines, additional information supporting medical necessity is welcome and may be utilized by the medical director in reviewing the case. Please note that all Presbyterian Medical Policies are available online at: Click here for Medical Policies

Web links: At any time during your visit to this policy and find the source material web links has been updated, retired or superseded, PHP is not responsible for the continued viability of websites listed in this policy.

When PHP follows a particular guideline such as LCDs, NCDs, MCG, NCCN etc., for the purposes of determining coverage; it is expected providers maintain or have access to appropriate documentation when requested to support coverage. See the References section to view the source materials used to develop this resource document.

Not every Presbyterian health plan contains the same benefits. Please refer to the member's specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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