CMM-609: Lumbar Fusion (Arthrodesis)

Lumbar fusion is covered only for specific instability‑related or defined structural indications (actual or anticipated iatrogenic instability meeting imaging thresholds such as >3 mm translation on flexion‑extension or Meyerding Grade II+, select single‑level discogenic DDD after failed nonoperative care, recurrent/complex herniations, adjacent‑segment disease, failed arthroplasty, pseudarthrosis/hardware failure, select deformity and urgent/emergent conditions) and is not medically necessary for isolated neurocompressive pathology, multi‑level DDD without instability, facet disorders without instability, spondylolysis without spondylolisthesis, initial discectomy/laminectomy without instability, or procedures/devices listed as experimental/investigational. Key requirements include recent confirmatory imaging (typically within 6 months) showing the required instability/degeneration criteria, documentation of specified conservative therapy durations (e.g., ≥2 conservative measures for ≥6 weeks for fusion with decompression; generally ≥3 months of analgesics or provider‑directed exercise for fusion without decompression; discogenic single‑level DDD requires ≥12 months of multimodal nonoperative care with ≥2 modalities), and nicotine‑free status (never‑smoker or ≥6 weeks abstinent with blood cotinine ≤10 ng/mL), plus other condition‑specific clinical documentation.