CMM-612 Grafts

rhBMP‑2 (InFuse®) is covered only for specific spinal fusions (selected anterior/posterior cervical with defined high‑risk features, stand‑alone ALIF in skeletally mature patients, and PLF/PLIF/TLIF when predefined high‑risk criteria are met) and routine cervical, routine pediatric, appendicular, and many other orthobiologic uses (e.g., rhBMP‑7, most cell‑based substitutes like Osteocel®/ViviGen®/Trinity®, PRP, certain allograft/ceramic products) are excluded. Key requirements: all listed criteria and documentation must be met (absence of contraindications such as pregnancy/allergy; documentation of the specific approved fusion procedure and high‑risk factors or inadequate autograft as applicable; prior authorization per CMM‑600.1), and BMAC is covered only when harvested by the sequential/Muschler technique and used as a hybrid/composite graft with autologous ICBG for posterolateral lumbar fusion (other BMAC uses and techniques are not covered).

"Recombinant human bone morphogenetic protein-2 (rhBMP-2) (InFuse®) is considered medically necessary when performed for spinal fusion surgeries (only) when ALL associated criteria for the applicabl..."