Cervical Fusion

Cervical fusion is covered when clinical findings (e.g., radicular arm pain ≥4/10 for ≥12 weeks with failed multimodal conservative therapy, neurologic deficits impacting ADLs, or specified exceptions) are correlated with imaging (MRI/CT) demonstrating stenosis, degenerative findings, tumor, infection, ossification, or instability (translation >3.5 mm or angulation >11°). Fusion is also reasonable for traumatic instability, tumors causing or likely to cause instability, infections with vertebral destruction, and specified deformities or symptomatic pseudoarthrosis when documented functional limitation or progression is present. Isolated axial neck pain and asymptomatic myelopathy are not covered, and all claims must include documented clinical findings, imaging with measurements, documentation of conservative therapy (when required), and appropriate provider credentials.

"Persistent or recurrent moderate to severe arm pain (VAS >= 4/10 or equivalent) present for a minimum of 12 weeks within the current episode with documented failure to respond to multimodal conserv..."