CMM-614 Thoracic and Thoracolumbar Fusion (Arthrodesis)

Thoracic and thoracolumbar fusion (and adjunctive osteotomies) are medically necessary only when the guideline’s specific clinical and imaging criteria are met (e.g., deformity thresholds, instability such as dynamic translation >3 mm or Meyerding Grade II+), and are excluded for sole indications like multilevel degenerative disc disease without instability or isolated facet disorders; endoscopic/percutaneous fusion and isolated facet fusion devices are considered experimental/investigational. Key requirements include confirmatory imaging with specified measurements, documented conservative-treatment failure where required, nicotine-free status (cotinine ≤10 ng/mL or never-smoker), absence of unmanaged significant mental/behavioral health disorders, adherence to timing rules for adjacent/repeat fusions and pseudoarthrosis, and urgent/emergent cases may waive some non-surgical, smoking, and behavioral-health prerequisites.

"Adjacent segment disease: prior thoracic fusion at adjacent level must have been performed at least 6 months prior."