Blue Cross of Idaho
Spinal Surgery Prior-authorization Guidelines

Subject          LUMBAR AND CERVICAL FUSION (arthrodesis) (New cervical guidelines effective December 1, 2009)

Next Review       4/2010

Description

Back and neck pain, with and without radicular symptoms, is one of the most common complaints for which members seek medical care.  This set of diagnoses is one of the highest direct healthcare cost categories and significantly impacts indirect costs to employers due to lost workdays and work-related claims.

Permanent disability is a common outcome of back injury and pain. One study¹ indicated that workers with back complaints who are off work over 6 months have only a 50% possibility of ever returning to productive employment. If they are off work over one year this possibility drops to 25%, and if more than 2 years, it is almost nil.

There is also significant geographic variablility in the treatment of back pain and radiculopathy. According to the Dartmouth Atlas of Healthcare, patients in Idaho are four times more likely to undergo back surgery than patients in regions with the lowest rates without differences in outcomes.

To improve communication related to authorization for lumbar spinal surgery, we have separated the guideline into two general categories:

1. Surgery related to the treatment of sciatica or other nerve root impingements where primary intervention is related to removal of an offending herniated disk.
2. Surgery related to mechanical and anatomical abnormalities for which spinal fusion may be appropriate treatment.

These guidelines do not apply to patients with traumatic spinal fractures or dislocations, primary infections, or neoplasms of the spine. 

Policy for Lumbar Spinal Fusion

General Requirements for Lumbar Spinal Fusion: In the absence of red flag symptoms or progressive neurological symptoms or signs, members presenting with low back pain should undergo conservative therapy, which may include the use of anti-inflammatory medications, aggressive physical therapy with home exercise program, activity modification, physical reconditioning or facet or epidural injections. A patient should undergo at least 12 weeks of conservative management for symptomatic spinal stenosis or spondylolosthesis. Patients with only axial low back pain (absence of leg symptoms) and without demonstrable instability, spondylolisthesis or spinal stenosis should go through conservative therapy for at least six months.

1. The requesting surgeon should have personally evaluated the patient on at least two occasions prior to requesting surgery.
2.  As part of initial evaluation, there should be a functional assessment such as the SF-36 and/or Oswestry Disability Index. If the mental health component of the SF-36 indicates concern (usually scores less than 40), clinical psychological or psychiatric assessment should occur. This assessment should focus on helping the requesting surgeon identify specific psychological risk factors (chronic pain syndrome, depression) that may be barriers to successful treatment and/or recovery following surgery.
3. All members should be screened for medical co-morbidities and undergo thorough medical clearance as indicated.
4. Because of the high risk of pseudoarthrosis, a smoker anticipating a spinal fusion should undergo counseling and adhere to a smoking-cessation program that results in abstinence from smoking for at least six weeks prior to elective surgery.
5. Pre-authorization is required for elective procedures and physicians should submit requests to Blue Cross of Idaho`s Medical Management Department at least two weeks prior to the anticipated date of an elective surgery.
6. The minimal documents necessary to accurately and expeditiously complete pre-authorization requests for spinal fusion are:

LUMBAR FUSION

Personal evaluation by the surgeon on at least two separate occasions should take place for elective procedures.

Failure to improve after approximately three months of conservative therapy for low back pain that emphasizes physical reconditioning should be present in all cases.

Notes

Lumbar fusion is not indicated with an initial laminectomy/diskectomy related to unilateral decompression of a lumbar nerve root.

In a recent study from Dartmouth on the surgical treatment of spinal stenosis without spondylolisthesis, only 6 percent received a fusion.¹

Uncertainty remains concerning the relative merits of instrumented versus non-instrumented fusion. In the study by Weinstein et al., surgeons used pedicle screws in most fusions. Previous trials have suggested a small advantage of instrumentation in promoting solid bony fusion but little advantage in pain relief or functional recovery and a higher rate of complications creating a dilemma that deserves further scrutiny.²

The most common (and modifiable) patient-related behavior that affects the rate of fusion is smoking. Smoking can lead to a 33 percent decrease in the rate of fusion. Current smoking is a relative contraindication and smoking cessation for six weeks is required for approval unless there is a progressive neurologic deficit or extreme pain.

The use of spine stabilization devices in Washington workers doubled the chances of another surgery. The reoperation rate for all fusions within two years was approximately 23 percent.

CERVICAL FUSION

Cervical fusion refers to neck surgery during which two or more vertebral segments of the cervical spine are fused together with the goal of eliminating painful cervical neck motion, instability and providing additional space for the decompressed spinal cord and nerves. Cervical fusion maybe necessary for treatment of degenerative disc disease, and can be approached either anteriorly or posteriorly.

General requirements:

• The minimal documents necessary to accurately and expeditiously complete prio-authorization requests for spinal fusion are:
  • office notes, including history and physical
  • detailed documentation of extent and response to conservative therapy
  • Radiology reports for MRI`s, CT`s, etc...
  • flexion-extension films for spinal fusion requests based upon instability
  • medical clearance reports (as indicated)
  • documentation of smoking abstinence (as indicated)
  • specific procedures with CPT/ICD-9 codes and disc levels indicated

INDICATIONS FOR CERVICAL FUSION (POSTERIOR OR ANTERIOR):

Procedure may be indicated for 1 or more of the following:

• Unstable traumatic anterior column fracture, especially burst fracture Disk herniation with radiculopathy when ALL of the following are present
  • Unremitting radicular pain or progressive weakness secondary to nerve root compression
  • Failure of a full trial of nonsurgical management
• Multilevel spondylotic myelopathy, as evidenced by 1 or more of the following:
  • Clinical symptoms of myelopathy; examples include:
    • Clumsiness of hands
    • Urinary urgency
    • Bowel or bladder incontinence
    • Frequent falls
  • Clinical signs of myelopathy; examples include:
    • Hyperreflexia
    • Hoffmann sign 
    • Increased tone or spasticity
    • Loss of thenar or hypothenar eminence
    • Gait abnormality
    • Positive Babinski sign
• Diagnostic imaging positive for cord compression from either herniated disk or osteophyte
• Ossification of the posterior longitudinal ligament at 1 to 3 levels associated with myelopathy
• Degenerative cervical spondylosis with kyphosis causing cord compression
• Traumatic disk herniation associated with myelopathy
• Primary or metastatic tumor causing pathologic fracture, cord compression, or instability
• Spinal infectious disease
• Multilevel spondylotic radiculopathy
• Degenerative spinal segment adjacent to a prior decompressive or fusion procedure with 1 or more of the following :
  • Symptomatic myelopathy corresponding to the adjacent level
  • Symptomatic radiculopathy corresponding to the adjacent level and unresponsive to conservative care
• Other symptomatic instability or cord or root compression requiring anterior fusion with ALL of the following
  • Patient unresponsive to conservative therapy (eg, rest, medication, cervical collar)
  • Imaging study demonstrating corresponding pathologic anatomy

Active tobacco use

• Because of the high risk of pseudoarthrosis, a smoker anticipating a spinal fusion shall undergo counseling and adhere to a smoking-cessation program that results in abstinence from smoking for at least six weeks prior to elective surgery.
  
  

References:

1. (McGill, C.M. Industrial back problems.  Journal of Occupational Medicine, 10, 1740-1748) 1968
2. North American Spine Society, Unremitting Low Back Pain, version 1.0,Phase  Clinical Guidelines for Multidisciplinary Spine Care Specialists, 2000
3. McKesson: InterQual Clinical Evidence Summary: Low Back Pain, 2004
4. Washington State Department of Labor and Industries. Guidelines for lumbar fusion (arthrodesis). Olympia (WA): Washington. State Department of Labor & Industries;2002 Aug 5 p.
5. Impact of Smoking on the Outcome of Anterior Cervical Arthrodesis with Interbody or Strut-Grafting: Journal of Bone and Joint Surgery 83:668-673 (2001)
6. Comparing outcomes of anterior cervical discectomy and fusion in workman’s versus non-workman’s compensation population: The Spine Journal, Volume 2, Issue 6, P 408-414, November 2002