Spine Surgery Guidelines

Covers prior‑authorization medical necessity for elective cervical and lumbar spine procedures (e.g., ACDF, cervical total disc arthroplasty, posterior decompression/fusion, microdiscectomy, vertebral augmentation, lumbar fusion, SIJ fusion, bone growth stimulation) when specific indications are met, and excludes surgery for chronic non‑specific pain, many CDA contraindications (e.g., age <18 or >60, prior surgery at the treated level, low BMD T‑score ≤‑1.5, instability, active infection, severe facet arthropathy), and experimental/unproven devices/techniques; discography/MR spectroscopy are not endorsed. Key requirements: recent (typically ≤6 months) concordant MRI/CT and required plain X‑rays (often flexion/extension), documented failure of specified conservative treatments of defined durations (commonly ≥6 weeks for meds and exercise and often ESIs/SNRBs unless contraindicated), SIJ confirmation by two intra‑articular blocks with ≥75% pain relief when applicable, nicotine‑free documentation (never smoker or blood cotinine ≤10 ng/mL after ≥6 weeks cessation) with exceptions for urgent/emergent requests or myelopathy, and complete prior‑authorization documentation (imaging reports, treatment details, levels/CPT/ICD‑10 and rationale).