CMM-609: Lumbar Fusion (Arthrodesis)

Lumbar fusion and specified lumbar osteotomies are covered when strict indications are met — urgent instability/infection/neoplasm, defined adult/pediatric deformities, spondylolisthesis or anticipated iatrogenic instability, adjacent-level or repeat fusion per criteria, and osteotomies only when fusion criteria plus deformity-specific thresholds are met (posterior column osteotomy limited to 4 apical levels per surgery except Scheuermann’s); fusion is not covered for sole indications such as isolated disc herniation without instability, multi-level DDD without instability, facet pain without instability, adjunct fusion for stenosis without instability, or experimental/unproven procedures. Key requirements include confirmatory advanced imaging and concordant exam findings, procedure-specific conservative-treatment trials/durations (e.g., ≥3 months for degenerative spondylolisthesis, ≥12 months with ≥2 modalities for discogenic pain, 6 weeks for pseudoarthrosis), documentation of nicotine-free status (cotinine ≤10 ng/mL for many elective cases), post-op imaging timing (≥6 months for pseudoarthrosis), and adherence to CMM-609 subsections and CMM-608 criteria for decompression candidacy.