Spine Surgery Guidelines

This eviCore guideline covers specified cervical and lumbar spine surgeries (e.g., ACDF, posterior decompression/fusion, microdiscectomy, vertebral augmentation, bone-growth stimulation) for defined indications such as radiculopathy, myelopathy, instability, failed implants or adjacent‑segment disease, and excludes chronic non‑specific pain and numerous experimental/investigational scenarios (e.g., cervical TDA as sole indication or outside age/bone‑density/prior‑surgery limits). Coverage requires prior authorization (≥2 weeks before elective surgery) with recent (typically ≤6 months) concordant imaging, objective exam findings, documented failure of specified conservative therapies of defined durations, nicotine‑free status evidenced by blood cotinine ≤10 ng/mL (with urgent/emergent or myelopathy exceptions), flexion‑extension X‑rays when instability is suspected, and full supporting documentation including reconciled radiology reports.

"Urgent/emergent: primary or metastatic neoplastic disease causing pathologic fracture or cord compression when instability is present or resection/decompression anticipated to result in iatrogenic ..."