CMM-614: Thoracic and Thoracolumbar Fusion

Thoracic and thoracolumbar fusion is medically necessary only for specific deformity thresholds (e.g., coronal Cobb >30°; adult residual idiopathic scoliosis >50°; Scheuermann’s kyphosis >75°), decompression-related actual or anticipated instability (e.g., >3 mm dynamic translation, Meyerding Grade II+, or facet resection >50% bilaterally/≥75% of one facet), adjacent-segment disease, and select repeat-fusion scenarios, while fusion for sole indications such as multi-level degenerative disc disease without instability, isolated facet disorder without instability, initial discectomy/laminectomy without instability, and several minimally invasive/endoscopic/novel devices or isolated facet fusions is not covered or is investigational. Coverage requires confirmatory imaging and documented failure of conservative therapy (for decompression+fusion: ≥2 modalities ≥6 weeks; for fusion alone: ≥1 modality ≥3 months, unless contraindicated), documentation of nicotine-free status (cotinine ≤10 ng/mL) and absence of unmanaged behavioral health contributors, with exceptions for adolescent congenital/neuromuscular/juvenile scoliosis and urgent/emergent indications.