CMM-600: Preface to the Spine Surgery Guidelines

This guideline governs prior-authorization and medical‑necessity review for elective and urgent/emergent spine surgeries and related comprehensive musculoskeletal services (including spinal fusion and disc arthroplasty) and explicitly excludes using discography or MR spectroscopy as determinants of necessity. Key requirements include PA submission ≥2 weeks before elective surgery, independent radiologist CT/MRI/myelography reports (with reconciliation of surgeon–radiologist discrepancies), detailed documentation of provider‑directed non‑surgical treatment or contraindications, documented trials of ESIs/SNRBs or specified contraindications, nicotine‑free verification (cotinine ≤10 ng/mL after ≥6 weeks cessation) for fusion/disc arthroplasty unless urgent/emergent or myelopathy, and flexion‑extension/plain X‑rays for fusion when instability or hardware/fusion failure is a concern.

"Clinical scenarios involving radiculopathy (defined in document), spinal stenosis (defined in document), and motor deficits (weakness) where spine surgical review is indicated."