Spine Surgery Guidelines

eviCore covers specific cervical and lumbar spine procedures (e.g., ACDF, selected cervical/lumbar total disc arthroplasty, posterior decompression/fusion, microdiscectomy, vertebral augmentation, SIJ fusion, and select biologics) only when strict medical‑necessity criteria are met and expressly excludes procedures for chronic non‑specific pain, degenerative disc disease as the sole indication, many device/anatomic contraindications and numerous experimental/unproven interventions (e.g., semi‑invasive electrical bone stimulation, low‑intensity ultrasound, several bone‑stimulation indications). Coverage requires prior authorization (≥2 weeks for elective cases) with CPT/ICD and level details, independent radiology reports with imaging within specified timeframes (typically MRI/CT concordant with symptoms, cervical x‑rays within 6 months, implant‑failure imaging within 3 months), documented failure of structured conservative care (global ≥50% improvement assessment), nicotine‑free verification (cotinine ≤10 ng/mL or nonsmoker) for fusion and many procedures, absence of unmanaged behavioral health disorders, and specific diagnostic confirmations (e.g., SIJ blocks), with exceptions allowed for urgent/emergent indications.