Blue Cross of Idaho
Spinal Surgery Prior-authorization Guidelines
Subject CERVICAL FUSION (arthrodesis)
Next Review 06/2014
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 may be a necessary treatment for degenerative disc disease, and can be approached either anteriorly or posteriorly.
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 patient must have an appropriate indication for Cervical Spine Fusion as defined in the Indications for Cervical Spinal Fusion section below
3. The minimal documents necessary to accurately and expeditiously evaluate prior-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 of and response to conservative therapy, including outcomes of any procedural interventions, medication use and physical therapy 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. Medical clearance reports (as indicated)
f. Documentation of nicotine-free status – see Tobacco Cessation requirement 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*.
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 required above. Conservative care must include the following:
a. The use of prescription oral analgesic medications, preferably anti-inflammatories AND
b. 6 weeks of documented participation in a formal, active physical therapy program as directed by a physiatrist or physical therapist.
c. 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
d. 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. All members should be screened for medical co-morbidities and undergo thorough medical clearance as indicated.
8. Tobacco Cessation
a. Because of the high risk of pseudoarthrosis, a smoker 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.
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.
The following indications for cervical 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 cervical fusion with or without decompression 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 Cervical Spinal Fusion portion of this document):
1. Multilevel spondylotic myelopathy, as evidenced by 1 or more of the following:
a. Clinical signs and symptoms of myelopathy which may include: Clumsiness of hands, urinary urgency, new-onset bowel or bladder incontinence, frequent falls, hyperreflexia, Hoffmann sign, increased tone or spasticity, loss of thenar or hypothenar eminence, gait abnormality or pathologic Babinski sign
2. Herniated disk or osteophyte which has failed to improve with 6 weeks of coordinated conservative therapy as described above.
3. Ossification of the posterior longitudinal ligament at 1 to 3 levels associated with myelopathy
4. Degenerative cervical spondylosis with kyphosis causing cord compression
5. Disk herniation associated with myelopathy
6. Multilevel spondylotic radiculopathy which has failed to improve with 6 weeks of coordinated conservative therapy as described above
7. Spinal segment degeneration adjacent to a prior fusion with 1 or more of the following :
a. Symptomatic myelopathy corresponding to the adjacent level
b. Symptomatic radiculopathy corresponding to the adjacent level and unresponsive to 6 weeks of coordinated conservative therapy as described above
*Red flag symptoms may include; severe or rapidly progressive symptoms of motor loss, bowel or bladder dysfunction.
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.
- (McGill, C.M. Industrial back problems. Journal of Occupational Medicine, 10, 1740-1748) 1968
- North American Spine Society, Unremitting Low Back Pain, version 1.0,Phase Clinical Guidelines for Multidisciplinary Spine Care Specialists, 2000
- McKesson: InterQual Clinical Evidence Summary: Low Back Pain, 2004
- Washington State Department of Labor and Industries. Guidelines for lumbar fusion (arthrodesis). Olympia (WA): Washington. State Department of Labor & Industries;2002 Aug 5 p.
- 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)
- 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
- 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.
- 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
- American Academy of Orthopedic Surgeons (AAOS). Surgery and smoking. July 2007. Available at URL address: http://orthoinfo.aaos.org/topic.cfm?topic=A00262
- 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.
- SpineLine. Smoking and Fusion. September/October 2002.-Fardon MD, David.