Spine Surgery Guidelines

Covers rhBMP‑2 (InFuse®) only as medically necessary when ALL criteria are met for a single‑level anterior interbody lumbar/lumbo‑sacral fusion (ALIF) at L2–S1 in patients at high risk for fusion failure with autograft infeasible, and explicitly excludes cervical/thoracic or posterior lumbar use, skeletally immature patients, and numerous graft substitutes/biologics as experimental. Prior authorization (≥2 weeks) and detailed documentation are required — including concordant symptoms/objective findings with recent imaging (3–6 months), failure of specified conservative treatments, nicotine‑free status verified by cotinine (except myelopathy), FDA‑label device use, and other specified imaging/operative records; many other indications (e.g., discography‑based decisions, chronic non‑specific pain) are excluded.

"For vertebroplasty: The use of Norian XR cement and Norian SRS cement products is prohibited because they are not FDA approved."