20939
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.13
Facility
$61.46
Non-Facility
$61.46
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the guidelines titled Medical Records Documentation Used for Reviews.
- For InFUSE® lumbar indication: documentation of surgical approach (anterior or oblique) and that an FDA-approved interbody fusion device was used
- For InFUSE® lumbar indication: documentation that the individual is skeletally mature (18 years of age or older or radiographic evidence of epiphyseal closure)
- For InFUSE® lumbar indication: documentation of diagnosis of degenerative disc disease (DDD) and that fusion involves vertebral bodies L2-S1
Key Coverage Criteria
- Autografts [including Bone Marrow Aspirate (BMA) used for bone grafting]
- Demineralized Bone Matrix (DBM) without added products listed below as unproven and not medically necessary
- Allograft-based products not listed below as unproven and not medically necessary
- InFUSE® Bone Graft Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2) of the lumbar spine when all of the following criteria are met: the approach is anterior or oblique and used in conjunction with an FDA-approved interbody fusion device; skeletally mature individual (18 years of age or older or radiographic evidence of epiphyseal closure) with degenerative disc disease (DDD); the fusion involves vertebral bodies L2-S1, without or with spondylolisthesis of no more than grade 1 (25% displa [...]
- The InFUSE™/MASTERGRAFT™ Posterolateral Revision Device System (or InFUSE BMP used with MASTERGRAFT) when used according to U.S. Food and Drug Administration (FDA) indications, contraindications, warnings, and precautions in individuals who meet all of the following criteria: implanted via a posterolateral approach; presence of symptomatic posterolateral lumbar spine pseudoarthrosis; skeletally mature patient (older than 21 years of age or radiographic evidence of epiphyseal closure); autologous [...]
4 Active Policies
CARELON-spine-surgery-2024-01-01 — Spine Surgery
UHC-POL-spinal-fusion-bone-healing-products — Spinal Fusion and Bone Healing Enhancement Products
UMR-POL-UMR-spinal-fusion-bone-healing-products — Spinal Fusion and Bone Healing Enhancement Products
SUREST-POL-SUREST-spinal-fusion-bone-healing-products — Spinal Fusion and Bone Healing Enhancement Products
Related Codes
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