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Blue Cross of Idaho
Spinal Surgery Prior-authorization Guidelines

Subject          LUMBAR FUSION (arthrodesis)

Next Review       06/2014

General Requirements for Lumbar Spinal Fusion:

 

1.     Prior-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.

2.     The minimal documents necessary to accurately and expeditiously complete pre-authorization requests for spinal fusion are:

a.     Specific procedures requested with CPT/ICD-9 codes and disc levels indicated

b.    Office notes, including a current history and physical exam

c.     Detailed documentation of extent and response to conservative therapy, including outcomes of any procedural interventions, medication use and physical therapy/physiatry notes

d.    Most recent radiology reports for MRI`s, CT`s, etc. Imaging must be performed and read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede.

e.     Flexion-extension films for spinal fusion requests based upon instability

f.     Oswestry Disability Index or results of SF-36. Forms must be signed and dated by the member.  Psychiatric evaluation may be required based on the results of these tests.

g.    Medical clearance reports (as indicated)

h.     Documentation of nicotine-free status – see Tobacco Cessation requirement below.

3.     The patient must have an appropriate indication for Lumbar Spinal Fusion as defined in the Indications for Lumbar Spinal Fusion section below

4.     The patient must have significant symptoms that correlate with physical exam findings AND radiologist-interpreted imaging reports including:

a.     Significant functional impairment or loss of function resulting in inability or significantly decreased ability to perform normal, daily activities of work, school, or at-home duties.

b.    Persistent, debilitating pain is defined as: Significant level of pain on a daily basis defined on a Visual Analog Scale (VAS) as greater than 4.  Pain on a daily basis that has a documented negative impact on activities of daily living despite optimal conservative therapy as described below.

The following guidelines may not apply to patients with traumatic spinal fractures or dislocations, primary infections, neoplasms of the spine or those with “red-flag” symptoms such as severe or rapidly progressive symptoms of motor loss, neurogenic claudication or cauda equina syndrome.

5.     The requesting surgeon should have personally evaluated the patient on at least two occasions prior to requesting surgery.

6.     Patient has participated in optimal conservative care for the indication-specific duration as specified in the Indications for Lumbar Spinal Fusion section below.Lumber fusion surgery is considered not medically necessary when the patient demonstrates substantial improvement on clinical re-evaluation as a result of these measures.  Conservative care must include the following:

a.     The use of prescription oral analgesic medications, preferably anti-inflammatories  AND

b.    Documented participation in a formal, active physical therapy program or through a Blue Cross of Idaho Spine Center of ExcellenceAND

c.     Evaluation and appropriate management of associated behavioral, cognitive, and addiction issues if present (See requirement #7 below for additional information).

d.    Other conservative measures which may not be substituted for those above but which may be used adjunctively can include:

§ A home exercise program

§ Activity modification, as appropriate

§ Facet or epidural injections

§ Other measures

e.    The purpose of performing conservative measures is not to simply fulfill surgical pre-requisites or add complexity to the pre-authorization process.  According to best-practice guidelines and evidence-based medicine, initial and preferred long-term treatments for back pain are conservative in nature.  It is recognized that some individuals with back pain will require surgery.  Many patients will obtain lasting benefit from conservative treatments and thus avoid more invasive procedures.  One of the primary goals of this policy is to help identify and most appropriately manage these patients. 

7.     Psychological risk factors have been identified

a.     Psychological ractors have a significant impact on spine surgery outcomes (23-33). In order to help facilitate successful treatment and recovery, it is important to provide psychological evaluation for patients most-likely to benefit from this service.

b.    One of the following measurement tools must be completed, signed and submitted:

§ SF-36

§ Oswestry Disability Index

§ Zung Depression Scale or Beck's Depression Inventory

c.     Pre-operative psychological evaluation by a psychologist (PhD) must be submitted when:

§ The patient has a score of:

§ SF-36 mental health component <36 OR

§ Oswestry Disability Index >60 OR

§ Zung Depression Scale ≥ 50, Beck Depression Inventory >20 OR

§ The patient has a mental health condition that is not well-controlled (eg., non-compliance, hospitalizations, active medication changes) OR

§ The patient has a substance abuse condition (other than tobacco) OR

§ The patient is regularly using opioids for chronic pain management (>6months) OR

§ The patient previously had spinal surgery without benefit OR

§ The requesting surgeon feels that the patient may benefit from such evaluation.

d.    The purpose of psychological evaluation is to help identify and address psychological barriers to successful treatment, including those that may be undiagnosed (eg., chronic pain syndrome, depression, somatization, etc.)

e.    If psychological factors requiring treatment are identified and surgery is still deemed appropriate, a treatment plan from the evaluating psychologist must be submitted. This may include pre-operative and post-operative interventions.

f.    If further psychological testing is warranted based on the psychologist's initial diagnostic evaluation, this should be requested by the psychologist through the standard prior-authorization process.

8.     All members should be screened for medical co-morbidities and undergo thorough medical clearance as indicated.

9.     Tobacco Cessation

a.     Because of the high risk of pseudoarthrosis, a patient anticipating a spinal fusion will adhere to a tobacco-cessation program that results in abstinence from tobacco for at least six weeks prior to elective surgery. (11)(18)(19)(20)(21)

b.    Documentation of nicotine-free status by lab result (cotinine level) in patients who have been documented tobacco-users is required. Labs are to be performed after 6 weeks tobacco cessation and ample time should be afforded to submit this confirmation and complete the prior authorization process.

 

Indications for Lumbar Spinal Fusion

 

The following indications for lumbar fusion are considered Medically Necessary

1.     Unstable traumatic spine fracture or dislocation

2.     Primary or metastatic tumor causing pathologic fracture, cord compression, or instability

3.     Spinal infectious disease

The following indications for lumbar fusion may be considered Medically Necessary when all other reasonable causes of pain have been ruled-out and all other requirements have been met (as described in the General Requirements for Lumbar Spinal Fusion portion of this document):

1.     Spinal stenosis

a.     In the presence of documented central/lateral recess/or foraminal stenosis, on MRI or other imaging, associated with spondylolisthesis. This must be demonstrated on plain x-rays which show 5 mm or more of translation or  Grade 2 on the Meyerding grading system and one of the following:

§ Neurogenic claudication or radicular pain that has resulted in significant functional impairment despite at least 12 weeks of coordinated conservative including:

o    Interventional procedures such as ESI

o    Optimized pharmacologic therapies

o    Physical therapies

§ “Red flag” symptoms such as severe or rapidly progressive symptoms of motor loss, neurogenic claudication or cauda equina syndrome. 

2.     Severe, progressive, idiopathic scoliosis (lumbar or thoracolumbar)

a.     Cobb angle >40 degrees.

3.     Severe degenerative scoliosis with any one of the following:

a.     Documented progression of deformity with persistent axial pain and impairment or loss of function, unresponsive to at least 12 weeks of coordinated conservative care (as described above in #6 under General Requirements for Lumbar Spinal Fusion). or

b.    Persistent and significant neurogenic symptoms (radicular pain or claudication) with impairment or loss of function unresponsive to at least 12 weeks of coordinated conservative care.

4.     Isthmic spondylolisthesis with

a.     Congenital or acquired pars defect, documented by x-ray AND

b.    Persistent back pain (with or without neurogenic symptoms) AND

c.     Impairment and loss of function, unresponsive to at least 6 months of coordinated conservative care (as described above in #6 under General Requirements for Lumbar Spinal Fusion).

5.     Recurrent disc herniation

a.     For same-level disk herniation after two prior discectomies at that level.

b.    Neural structure compression must again be demonstrated by most-recent imaging.

c.     Patient must have experienced significant initial relief of symptoms following prior discectomies.

d.    There must be at least a 6 months’ time span since the most recent disk surgery.

e.     For the current episode, the patient must have recurrent neurogenic symptoms and impairment or loss of function that has not responded to a minimum of 12 weeks of coordinated conservative care as described above (as described above in #6 under General Requirements for Lumbar Spinal Fusion).

6.     Adjacent segment degeneration with

a.     Neural structure compression demonstrated by appropriate imaging

b.    Patient must have experienced significant initial relief of symptoms following prior fusion(s)

c.     There must be at least a 6 months’ time span since the previous fusion.

d.    For the current episode, the patient must have recurrent neurogenic symptoms and impairment or loss of function that has not responded to a minimum of 12 weeks of coordinated conservative care (as described above in #6 under General Requirements for Lumbar Spinal Fusion).

7.     Pseudoarthrosis

a.     Patient must have persistent axial back pain

b.    Patient must have experienced significant initial relief of symptoms following prior fusion(s)

c.     Pseudoarthrosis is confirmed on imaging

d.    There must be at least a 6 months’ time span since the previous fusion

8.     Iatrogenic or degenerative flat back syndrome with significant sagittal imbalance

9.     Patients who have had previous decompressive surgery resulting in 75% unilateral facet loss or 50% bilateral facet loss and require additional surgery that would result in instability.

The following indications for lumbar spine fusion are considered investigational

1.     Sacroiliac Joint Fusion
Sacroiliac Joint Fusion including minimally invasive and percutaneous sacroiliac joint fusion for the treatment of sacroiliac joint and mechanical low back pain.  Reported clinical outcomes are mixed and therefore no strong conclusions can be made regarding safety and efficacy when performed for the treatment of mechanical back pain. (15)

2.     Degenerative Disc Disease
Degenerative disc disease (DDD) is considered a normal part of the aging process. Clinical symptoms are typically consistent with mechanical back pain, which is aggravated by activity and relieved by rest. In contrast to conditions resulting in instability, DDD is described as axial spine pain with no or minimal abnormalities of spinal alignment or disc contour. Treatments are conservative and involve patient education regarding the disease process, activity modification, physical therapy focusing on muscle strengthening and analgesics (e.g., non-steroidal anti-inflammatory, local injection).  Lumbar fusion is associated with more risks than conservative treatment, and when compared to structured rehabilitation and behavioral therapy programs there is no meaningful difference in clinical outcomes (e.g., pain relief, functional improvement) (13).  Discography is not encouraged in the assessment of these patients due to questionable clinical relevance and potential adverse effects.  Discography results will not be considered as an indication for surgery.

3.     Facet syndrome
Management of facet syndrome should be conservative and may include physical therapy, anti-inflammatories and facet injections.  According to the International Society for the Advancement of Spine Surgery (ISASS 2011), lumbar fusion for facet syndrome is no longer generally accepted and should only be performed in the context of a clinical trial.

The following sole indications for lumbar fusion are considered Not Medically Necessary:

1.     Initial diskectomy/laminectomy for neural structure decompression.
The North American Spine Society (NASS) published evidence based guidelines for the diagnosis and treatment of degenerative lumbar spinal stenosis in 2007. According to the guidelines regarding the results of medical/interventional management of spinal stenosis:

a.     Of patients with mild to moderate lumbar spinal stenosis initially receiving medical/interventional treatment and followed for two to 10 years, approximately 20-40% will ultimately require surgical intervention. Of the patients who do not require surgical intervention, 50-70% will have improvement in their pain.

b.    In patients with severe symptoms of lumbar spinal stenosis, decompressive surgery alone is effective approximately 80% of the time.

c.     In patients with lumbar spinal stenosis and spondylolisthesis, decompression with fusion results in better outcomes than decompression alone.

d.    Of patients with lumbar spinal stenosis without spondylolisthesis or instability, there is no evidence to support the addition of a fusion.  

2.     Spinal stenosis without spondylolisthesis
Fusion is indicated only if there is radiographic evidence of instability (e.g., spondylolisthesis). Spinal instability associated with stenosis may arise intraoperatively; cases of severe stenosis require more extensive decompression (i.e., complete facetectomy or resection of pars interarticularis creating a pars defect), which may destabilize the spine. According to a policy statement published by ISASS (2011) on lumbar fusion surgery, fusion is indicated when an adequate decompression for the treatment of spinal stenosis requires creation of a pars defect or removal of either 75% of one facet joint or >50% of both facet joints.

3.     Back pain without imaging to support the need for fusion as specified above

4.     In patients who are using tobacco and do not have “red-flag” symptoms:
Such as severe or rapidly progressive symptoms of motor loss, neurogenic claudication or cauda equina syndrome.  
 


 

Regarding Medicare Advantage Patients:

Medicare Advantage follows the medical policies of the Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) for the Medicare contractors in the state of Idaho.

If no NCD or Idaho LCD policy exists on the topic, it defaults to Blue Cross of Idaho commercial policy for medical necessity determination.

North American Spine Society (www.spine.org) accessed  1/13

NASS Clinical Guidelines - Degenerative Spinal Stenosis

Medical/interventional treatment may be considered to provide long-term (2-10 years) improvement in patients with degenerative lumbar spinal stenosis and has been shown to improve outcomes in a large percentage of patients.

            Grade of Recommendation: C

Decompressive surgery is suggested to improve outcomes in patients with moderate to severe symptoms of lumbar spinal stenosis.

            Grade of Recommendation: B

NASS Clinical Guidelines – Degenerative Lumbar Spondylolisthesis

Surgery is recommended for treatment of patients with symptomatic spinal stenosis associated with low grade degenerative spondylolisthesis whose symptoms have been recalcitrant to a trial of medical/interventional treatment.

            Grade of Recommendation: B

Direct surgical decompression is recommended for treatment of patients with symptomatic spinal stenosis associated with low grade degenerative lumbar spondylolisthesis whose symptoms have been recalcitrant to a trial of medical/interventional treatment.

            Grade of Recommendation: I (Insufficient Evidence)

Indirect surgical decompression is recommended for treatment of patients with symptomatic spinal stenosis associated with low grade degenerative lumbar spondylolisthesis whose symptoms have been recalcitrant to a trial of medical/interventional treatment.

            Grade of Recommendation: I (Insufficient Evidence)

Surgical decompression with fusion is recommended for the treatment of patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis to improve clinical outcomes compared with decompression alone.

            Grade of Recommendation: B

The addition of instrumentation is recommended to improve fusion rates in patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis.

            Grade of Recommendation: B

The addition of instrumentation is not recommended to improve clinical outcomes for the treatment of patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis.

            Grade of Recommendation: B

Decompression and fusion is recommended as a means to provide satisfactory long-term results for the treatment of patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis.

            Grade of Recommendation: C

References: 

  1. Blue Cross of North Carolina Medical Policy – Lumbar Spine Fusion Surgery
  2. Cigna Medical Coverage Policy – Lumbar Fusion for Spinal Instability and Degenerative Disc Conditions including Sacroiliac Fusion
  3. Aetna – Clinical Policy Bulletin; Spinal Surgery: Laminectomy and Fusion
  4. Weinstein, JN, et al.  Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis.  NEJM 2007; 356(22):2257-70
  5. Brown WC, Orme TJ, Richardson H. The rate of pseudoarthrosis (surgical nonunion) in patients who are smokers and patients who are nonsmokers: a comparison study. Spine 1986; 11:942-943.
  6. Brox JI, Sorensen R, Friis A, Nygaard O, Indahl A, Keller A, Ingebrigtsen T, Eriksen HR, Holm I, Koller AK, Riise R, Reikeras O. Randomized controlled 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.
  7. Fairbank J, Frost H, Wilson-MacDonald J, Yu L, Barker K, Collins R. Randomized controlled trial to compare surgical stabilization of the lumbar spine with an intensive rehabilitation program for patients with chronic low back pain: the MRC spine stabilization trial. BMJ 2005; 330(7502):1233.
  8. Brox JI, Reikeras O, Nygaard O, Sorensen R, Indahl A, Holm I, Keller A, Ingebrigtsen T, Grundnes O, Lange JE, Friis A. 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; 122:145-155.
  9. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010 Apr 7;303(13):1259-65
  10. Deyo RA, Nachemson A, Mirza SK. Spinal-fusion surgery—the case for restraint. N Engl J Med. 2004 Feb;350(7):722-6.
  11. Brown CW, Orme TJ, Richardson HD. The rate of pseudoarthrosis (surgical nonunion) in patients who are smokers and patients who are nonsmokers: a comparison study. Spine (Phila Pa 1976). 1986 Nov;11(9):942-3.
  12. Esses SI, Moro JK. The value of facet joint blocks in patient selection for lumbar fusion. Spine. 1993 Feb;18(2):185-90.
  13. Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine.
  14. Washington State Health Care Authority. Health technology Assessment. Spinal Fusion and Discography. For chronic low back pain and uncomplicated lumbar degenerative disc disease.
  15. Tang G, Rodts G, Haid RW Jr. Patient selection in lumbar arthrodesis for low back pain. In: Haid RW Jr., Resnick DK, editors. Surgical management of low back pain. Rolling Meadow, IL: American Association of Neurological Surgeons; 2001. Chapter 2. Accessed October 29, 2009
  16. International Society for Advancement of Spine Surgery (ISASS). Policy Statement on Lumbar Spinal Fusion Surgery. July 15, 2011
  17. Buchowski, et al., 2005; Zelle, et al., 2005; Cohen, et al., 2005; Shutz and Grob, 2006
  18. American Academy of Orthopaedic Surgeons (AAOS). Position statement: The effects of tobacco exposure on the musculoskeletal system. © 1995-2011 AAOS. ‒. Available at URL address: http://www.aaos.org/about/papers/position/1153.asp
  19. American Academy of Orthopedic Surgeons (AAOS). Surgery and smoking. July 2007. Available at URL address: http://orthoinfo.aaos.org/topic.cfm?topic=A00262
  20. SpineLine. The effects of Smoking on the Spine: A focus Review. September/October 2002.-Perkins MD, Richard,B., Slosar MD, Paul,J. Snook MD, Derek., SpineCare Medical Group.
  21. SpineLine. Smoking and Fusion. September/October 2002.-Fardon MD, David.
  22. (Washington State Department of Labor and Industries, 2002; Hanley, David, 1999; Tang, et al., 2001)
  23. Abbott AD, Tyni-Lenné R, Hedlund R. Leg pain and psychological variables predict outcome 2-3 years after lumbar fusion surgery. Eur Spine J. 2011 Oct;20(10):1626-34.

  24. Abbott AD, Tyni-Lenné R, Hedlund R. The influence of psychological factors on pre-operative levels of pain intensity, disability and health-related quality of life in lumbar spinal fusion surgery patients. Physiotherapy. 2010 Sep;96(3):213-21.

  25. Block AR, Ohnmeiss DD, Guyer RD, Rashbaum RF, Hochschuler SH. The use of presurgical psychological screening to predict the outcome of spine surgery.  Spine J. 2001 Jul-Aug;1(4):274-82.

  26. Chaichana KL, Mukherjee D, Adogwa O, Cheng JS, McGirt MJ. Correlation of preoperative depression and somaticperception scales with postoperative disability and quality of life after lumbar discectomy. J Neurosurg Spine. 2011 Feb;14(2):261-7.

  27. Derby R, Lettice JJ, Kula TA, Lee SH, Seo KS, Kim BJ. Single-level lumbar fusion in chronic discogenic low-back pain: psychological and emotional status as a predictor of outcome measured using the 36-item Short Form. J Neurosurg Spine. 2005 Oct;3(4):255-61.

  28. Hee HT, Whitecloud TS 3rd, Myers L. The effect of previous low back surgery on general health status: results from the National Spine Network initial visit survey of patients with low back pain. Spine (Phila Pa 1976). 2004 Sep 1;29(17):1931-7.

  29. LaCaille RA, DeBerard MS, Masters KS, Colledge AL, Bacon W. Presurgical biopsychosocial factors predict multidimensional patient: outcomes of interbody cage lumbar fusion. Spine J. 2005 Jan-Feb;5(1):71-8.

  30. Mannion AF, Elfering A, Staerkle R, Junge A, Grob D, Dvorak J, Jacobshagen N.  Predictors of multidimensional outcome after spinal surgery.  Eur Spine J (2007) 16:777–786.

  31. Pollock R, Lakkol S, Budithi C, Bhatia C, Krishna M. Effect of psychological status on outcome of posterior lumbar interbody fusion surgery. Asian Spine J. 2012 Sep;6(3):178-82.

  32. Sinikallio S, Aalto T, Airaksinen O, Lehto SM, Kröger H, Viinamäki H. Depression is associated with a poorer outcome of lumbar spinal stenosis surgery: a two-year prospective follow-up study. Spine (Phila Pa 1976). 2011 Apr 15;36(8):677-82.

  33. Trief PM, Grant W, Fredrickson B. A prospective study of psychological predictors of lumbar surgery outcome. Spine (Phila Pa 1976). 2000 Oct 15;25(20):2616-21.