0202T — Post vert arthrplst 1 lumbar
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Patient age documented (must be between 35 and 80 years).
- Imaging documentation (MRI/CT/standing radiographs) confirming one-level degenerative spondylolisthesis ≤ Grade 1 and level(s) L3–L5.
- Imaging or operative documentation demonstrating moderate to severe lumbar spinal stenosis and evidence of ligamentum flavum thickening and/or scarring of the facet joint capsule at the affected level.
- Operative plan/operative note indicating lumbar decompression and intent to use a motion-preserving implant (TOPS) rather than rigid fixation.
Key Coverage Criteria
- Implantation of a spinal prosthesis to restore posterior element structure and function as an adjunct to neural decompression
- Use of facet arthroplasty as an alternative to posterior spinal fusion
- Treatment of facet arthrosis
- Treatment of spinal stenosis
- Treatment of spondylolisthesis
- Implantation of prostheses to replace facet joints and excised posterior elements (facet arthroplasty).
6 Active Policies
BCBSIL-SUR712.034 — Facet Arthroplasty
BCBSMT-SUR712.034 — Facet Arthroplasty
BCBSNM-SUR712.034 — Facet Arthroplasty
BCBSOK-SUR712.034 — Facet Arthroplasty
REGENCE-SUR171 — Total Facet Arthroplasty
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