Cervical and Lumbar Spinal Procedures, MPM 25

1 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]. 1 Medical Policy Subject: Cervical and Lumbar Spinal Procedures Medical Policy #: Original Effective Date: 05/17/2010 Status: Reviewed Last Review Date: 05/26/2021 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 . Presbyterian now uses NIA Magellan Lumbar Spinal Surgery. NIA prior authorizes or manage the provider precertification for Musculoskeletal Surgery Services, and not the facility precertification.

2 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. This Medical Policy includes information on the following items (Ctrl+Click to select): Lumbar Spine Surgery Lumbar Spine Surgery Description Indication Exclusion Coding Lumbar Spinal Fusion (single level) Surgery Lumbar Spinal Fusion (multiple levels) Surgery Lumbar Decompression Procedures Lumbar Discectomy/Microdiscectomy procedure Cervical Spine Surgery Cervical Description Indications Coding Anterior Cervical Decompression with Fusion (ACDF) Single level Anterior Cervical Decompression with Fusion (ACDF) Multiple level: Cervical Posterior Decompression with Fusion Single Leve Cervical 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 SURGERY Not every Presbyterian health plan contains the same benefits.

3 Please refer to the member s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001]. 2 Lumbar Spine Surgery Lumbar Spinal Fusion Surgery Lumbar Decompression Procedures Lumbar Microdiscectomy Only Procedures Description This guideline outlines the key surgical treatments and indications for common Lumbar Spinal 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 treatment modalities for Lumbar spine disorders into surgical categories: Lumbar discectomy/microdiscectomy, Lumbar decompression, and Lumbar fusion 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 to potentially limit the incidence of adjacent segment degeneration. Presbyterian Health Plan covers Cervical artificial disc replacement, but does not cover Lumbar artificial disc replacement Indication INDICATIONS FOR Lumbar 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 pre-sacral spine surgery categories.)

4 I. Indications for Lumbar Discectomy/Microdiscectomy: Surgical indications for intervertebral disc herniation: II. Indications for Lumbar Decompression: Laminectomy, Laminotomy, Facetectomy, and Foraminotomy. These procedures allow decompression by partial or total removal of various parts of vertebral bone and ligaments. Surgical Indications for Spinal canal decompression due to Lumbar Spinal stenosis: III. Indications for Lumbar Spine Fusion: IV. CONTRAINDICATIONS FOR SPINE SURGERY (Note:Cases will not be approved if the below contraindications exist): 1. Medical contraindications 2. Psychosocial risk factors. 3. Active Tobacco or Nicotine 4. Morbid Obesity V. Other ADDITIONAL INFORMATION 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, or Lumbar Artificial Disc Replacement CODING The coding listed in this medical policy is for reference only.

5 Covered and non-covered codes are within this list. CPT Code Lumbar Spinal Fusion (single level) Surgery 22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace; Lumbar 22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace; (other than for decompression); Lumbar 22612 Arthrodesis, posterior or posterolateral technique, single level; Lumbar (with lateral transverse technique, when performed) 22630 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]. 3 CPT Code Lumbar Spinal Fusion (single level) Surgery 22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace, single interspace and segment; Lumbar For CPT codes listed above include also Decompression (see below for codes) CPT Code Lumbar Spinal Fusion (multiple levels) Surgery 22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace; Lumbar +22534 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace; thoracic or Lumbar , each additional vertebral segment 22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace; Lumbar +22585 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace; each additional interspace.

6 (List separately in addition to code for primary procedure) Code first (22554-22558) 22612 Arthrodesis, posterior or posterolateral technique, single level; Lumbar +22614 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) 22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace, single interspace; Lumbar +22632 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) 22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace, 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, single interspace and segment; each additional interspace and segment.

7 (List separately in addition to code for primary procedure). Code first (22633) For CPT codes listed above include also Decompression (see below for codes) CPT Code Lumbar Decompression Procedures 63005 Laminectomy with exploration and/or decompression of Spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy ( , Spinal stenosis), 1 or 2 vertebral segments; Lumbar , except for spondylolisthesis. 63012 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) 63017 Laminectomy with exploration and/or decompression of Spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, more than 2 vertebral segments; Lumbar 63030 Laminotomy, with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, Lumbar +63035 Laminotomy, with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, Cervical or Lumbar .

8 (List separately in addition to code 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 of Benefits to determine coverage [MPMPPC051001]. 4 CPT Code Lumbar Decompression Procedures 63042 Laminotomy, (hemilaminectomy) with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; Lumbar +63044 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) 63047 Laminectomy, facetectomy and foraminotomy, (unilateral or bilateral with decompression of Spinal cord, cauda equine and/or nerve root[s].)

9 [ , Spinal or lateral recess stenosis]), (single vertebral segment; Lumbar +63048 Laminectomy, facetectomy and foraminotomy, (unilateral or bilateral with decompression of Spinal cord, cauda equine and/or nerve root[s]. [ , 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). 63056 Transpedicular approach with decompression of Spinal cord, equina and/or nerve root(s), single segment; Lumbar . +63057 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) CPT Codes Lumbar Discectomy/Microdiscectomy procedure 63030 Laminotomy, with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, Lumbar +63035 Laminotomy, with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, Cervical or Lumbar .)

10 (List separately in addition to code for primary procedure). Code first (63020-63030) 62380 Endoscopic decompression of Spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, Lumbar . CPT Codes Lumbar Artificial Disc Replacement (not payable, considered investigational) 22857 Total disc arthroplasty, anterior approach, including discectomy to prepare interspace, single interspace, Lumbar 22862 Revision including replacement of total disc arthroplasty, anterior approach, single interspace; Lumbar 22865 Removal of total disc arthroplasty, anterior approach, single interspace; Lumbar 0163T, 0164T and 0165T Add-on codes for the above procedures are also non covered. Cervical Spinal SURGERY Cervical Spine Surgery 1. Anterior Cervical Decompression with Fusion - Single Level (ACDF) 2. Anterior Cervical Decompression with Fusion - Multiple Level (ACDF) 3.