Lumbar Spinal Fusion

Lumbar spinal fusion is covered when the medical record documents at least one qualifying indication: radiographic/clinical instability from specified causes, symptomatic spinal deformity meeting defined functional and radiographic thresholds, revision fusion for pseudarthrosis meeting strict timing and diagnostic criteria, or symptomatic neural compression requiring disc excision. Documentation requirements include per-level evidence where applicable, ≥1 year of nonoperative care for deformity and pseudarthrosis criteria, verification of surgeon/OR/equipment for elective cases, and documented shared decision making and informed consent. Total disc arthroplasty is not covered and lack of documentation of an indication will result in noncoverage.

"Radiographic or clinical evidence of lumbar spinal instability due to congenital deformity, trauma, fracture, chronic degenerative condition, tumor, infection, erosive condition, space-occupying le..."