CMM-609: Lumbar Fusion (Arthrodesis)

Lumbar fusion and associated osteotomies (PCO limited to 4 segments except Scheuermann’s; PSO/VCR for >30° sagittal or >60° coronal correction), pediatric fusions, and fusion with decompression are covered only when all procedure‑specific criteria and numeric imaging thresholds are met (examples: dynamic translation >3 mm, SVA >8 cm, PI‑LL >15°, Cobb >30°) and certain specific disc herniation/instability scenarios apply; fusion/osteotomy performed without meeting these criteria or for listed sole indications (e.g., multilevel DDD without instability, disc herniation absent exceptions, facet pain alone) is not medically necessary. Key requirements include documented conservative care with specified minimum durations (e.g., ≥3 months for spondylolisthesis, up to 12 months for discogenic DDD where specified), required imaging and clinical documentation, nicotine‑free verification (never‑smoker or cotinine ≤10 ng/mL after ≥6 weeks abstinence), and prior authorization per CMM‑600.1, with exceptions for urgent/emergent cases.