Lumbar Spinal Fusion

This policy covers lumbar spinal fusion procedures for conditions such as spinal stenosis (when policy-specific stenosis criteria are met), spondylolisthesis, imaging-demonstrated spinal instability, neurogenic claudication or radicular pain, spinal cord compression/cauda equina, and severe or progressive scoliosis (juvenile, neuromuscular, congenital, or idiopathic). Coverage requires documented failure of optimal conservative non‑surgical therapy (therapeutic analgesic trial, anti‑inflammatory/adjunct use or documented intolerance, and typically ≥6 weeks of active physical therapy), evidence of significant functional impairment (eg, VAS>4) with concordant imaging of neural compression/instability; conservative therapy may be waived for red‑flag signs (rapid motor loss, cauda equina), and fusion is not medically necessary when the sole indication is disc herniation, chronic nonspecific low back pain, degenerative disc disease, or facet syndrome, with all coverage subject to the member’s plan terms and policy criteria.