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If you have questions about prior authorizations, please call:
Member and Recipient Service Line: 1-877-685-2415
Provider Support Service Line: 1-855-250-1539
Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; thoracic
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections.Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management.Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
The provider(s) shall submit the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met
the specific criteria in this policy.
The provider shall submit the following information along with the request for surgery:
- a. A signed letter of medical necessity clearly documenting diagnosis and
date of symptom onset, the specific procedure(s) requested with CPT code(s) and disc level(s) indicated;
- b. Office notes, including a current history and physical exam within the past
thirty days;
- c. Detailed documentation of extent and response to conservative medical
management, including length of treatment, outcomes of any procedural interventions, medication use (including dose and frequency), participation in physical therapy or a home exercise program, and beneficiary acceptance of recommended lifestyle modifications;
- d. All radiology reports relevant to the surgical request. Imaging must be
read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede;
- e. Post-operative plan of care; and
- f. Medical clearance reports (as appropriate).
- c. if the Medicaid beneficiary is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Exclusions
No posterior-cervical-fusion-specific non-coverage or exclusion language is stated in the provided packet. For beneficiaries under 21 years of age under EPSDT, Medicaid does not require coverage of any service, product, or procedure that is unsafe, ineffective, experimental or investigational, not medical in nature, or not generally recognized as an accepted method of medical practice or treatment.
Diagnosis Requirements
Coverage requires one or more of the following posterior-cervical-fusion-specific indications: - Concurrent stabilization with corpectomy, laminectomy, or another surgical procedure. - Symptomatic pseudoarthrosis from a prior fusion. - Subluxation or compression in rheumatoid arthritis. - Multilevel spondylotic myelopathy without kyphosis, evidenced by at least one of: clinical symptoms of myelopathy such as clumsiness of hands, urinary urgency, bowel or bladder incontinence, or frequent falls; clinical signs such as hyperreflexia, Hoffman sign, increased tone or spasticity, loss of thenar or hypothenar eminence, gait abnormality, or positive Babinski sign; or diagnostic imaging positive for cord compression from herniated disc or osteophyte. - Degenerative spondylosis with kyphosis causing spinal cord compression. - Unstable injuries consisting of atlas and axis fractures, disruption of posterior ligamentous structures, facet fractures with dislocation, bilateral locked facets, or central cord syndrome with multisegment injury.
- - Symptomatic cervical spondylosis with instability shown radiographically by at least one of: subluxation or translation of more than 3.5 millimeters on static lateral views or dynamic radiographs; sagittal plane angulation of more than 11 degrees between adjacent segments; or more than 4 millimeters of subluxation between the tips of the spinous processes on dynamic views. - Klippel-Feil syndrome. - Cervical instability in Down syndrome. - Cervical instability in skeletal dysplasia or connective tissue disorders.
- - Spinal tumor, abscess, or infection with associated cord compression or instability.
- - Other symptomatic instability or cord or root compression requiring posterior fusion, when both of the following are present: unresponsiveness to conservative care; and imaging study demonstrating corresponding pathologic anatomy.
Place of Service
Inpatient, Outpatient
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
Spinal Surgeries
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
The provider(s) shall submit the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met
the specific criteria in this policy.
- c. if the Medicaid beneficiary is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
The provider shall submit the following information along with the request for surgery:
- a. A signed letter of medical necessity clearly documenting diagnosis and
date of symptom onset, the specific procedure(s) requested with CPT code(s) and disc level(s) indicated;
- b. Office notes, including a current history and physical exam within the past
thirty days;
- c. Detailed documentation of extent and response to conservative medical
management, including length of treatment, outcomes of any procedural interventions, medication use (including dose and frequency), participation in physical therapy or a home exercise program, and beneficiary acceptance of recommended lifestyle modifications;
- d. All radiology reports relevant to the surgical request. Imaging must be
read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede;
- e. Post-operative plan of care; and
- f. Medical clearance reports (as appropriate).
Limits
Single-level procedure only.
Covered only for cervical artificial disc implantation from C3-4 to C6-7.
Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.
Exclusions
Medicaid shall not cover artificial disc implantation for the following conditions:
- 1. Planned simultaneous, multilevel disc implantation;
- 2. Combined use of artificial disc and fusion (hybrid procedure);
- 3. Prior surgery at the level to be treated;
- 4. Previous fusion at the same or adjacent level;
- 5. Instability as defined by translation greater than 3 millimeters’ difference
between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;
- 6. Anatomical deformity such as ankylosing spondylitis or previous
fracture;
- 7. Ossification of the posterior longitudinal ligament (OPLL)
- 8. Severe spondylosis defined as greater than fifty (50) percent disc height
loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;
- 9. Rheumatoid arthritis or other autoimmune disease;
- 10. Presence of facet arthritis;
- 11. Sensitivity or allergy to implant materials
- 12. Active systemic or site infection;
- 13. Metabolic bone disease such as osteoporosis, osteopenia, or
osteomalacia; or
- 14. Malignancy of the cervical spine.
- b. Medicaid shall not cover spinal surgery if the sole indication is any one or
more of the following conditions:
- 1. Disc herniation;
- 2. Annular tears;
- 3. Degenerative disc disease;
- 4. Initial discectomy or laminectomy for neural structure decompression;
- 5. Facet syndrome; or
- 6. Back pain without any clear cause on imaging
Place of Service
Inpatient, Outpatient.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
Spinal Surgeries
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
See Evolent site for specific requirements
Reauthorization Guidelines
See Evolent site for specific requirements
Limits
Single-level procedure only.
Covered only for cervical artificial disc implantation from C3-4 to C6-7.
Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.
Exclusions
Medicaid shall not cover artificial disc implantation for the following conditions:
- 1. Planned simultaneous, multilevel disc implantation;
- 2. Combined use of artificial disc and fusion (hybrid procedure);
- 3. Prior surgery at the level to be treated;
- 4. Previous fusion at the same or adjacent level;
- 5. Instability as defined by translation greater than 3 millimeters’ difference
between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;
- 6. Anatomical deformity such as ankylosing spondylitis or previous
fracture;
- 7. Ossification of the posterior longitudinal ligament (OPLL)
- 8. Severe spondylosis defined as greater than fifty (50) percent disc height
loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;
- 9. Rheumatoid arthritis or other autoimmune disease;
- 10. Presence of facet arthritis;
- 11. Sensitivity or allergy to implant materials
- 12. Active systemic or site infection;
- 13. Metabolic bone disease such as osteoporosis, osteopenia, or
osteomalacia; or
- 14. Malignancy of the cervical spine.
- b. Medicaid shall not cover spinal surgery if the sole indication is any one or
more of the following conditions:
- 1. Disc herniation;
- 2. Annular tears;
- 3. Degenerative disc disease;
- 4. Initial discectomy or laminectomy for neural structure decompression;
- 5. Facet syndrome; or
- 6. Back pain without any clear cause on imaging
Place of Service
Inpatient, Outpatient.
How to Submit
Please submit your request to Evolent
Resources
Spinal Surgeries
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
See Evolent site for specific requirements
Reauthorization Guidelines
See Evolent site for specific requirements
Limits
Single-level procedure only.
Covered only for cervical artificial disc implantation from C3-4 to C6-7.
Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.
Exclusions
Medicaid shall not cover artificial disc implantation for the following conditions:
- 1. Planned simultaneous, multilevel disc implantation;
- 2. Combined use of artificial disc and fusion (hybrid procedure);
- 3. Prior surgery at the level to be treated;
- 4. Previous fusion at the same or adjacent level;
- 5. Instability as defined by translation greater than 3 millimeters’ difference
between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;
- 6. Anatomical deformity such as ankylosing spondylitis or previous
fracture;
- 7. Ossification of the posterior longitudinal ligament (OPLL)
- 8. Severe spondylosis defined as greater than fifty (50) percent disc height
loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;
- 9. Rheumatoid arthritis or other autoimmune disease;
- 10. Presence of facet arthritis;
- 11. Sensitivity or allergy to implant materials
- 12. Active systemic or site infection;
- 13. Metabolic bone disease such as osteoporosis, osteopenia, or
osteomalacia; or
- 14. Malignancy of the cervical spine.
- b. Medicaid shall not cover spinal surgery if the sole indication is any one or
more of the following conditions:
- 1. Disc herniation;
- 2. Annular tears;
- 3. Degenerative disc disease;
- 4. Initial discectomy or laminectomy for neural structure decompression;
- 5. Facet syndrome; or
- 6. Back pain without any clear cause on imaging
Place of Service
Inpatient, Outpatient.
How to Submit
Please submit your request to Evolent
Resources
Spinal Surgeries
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
See Evolent site for specific requirements
Reauthorization Guidelines
See Evolent site for specific requirements
Limits
Single-level procedure only.
Covered only for cervical artificial disc implantation from C3-4 to C6-7.
Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.
Exclusions
Medicaid shall not cover artificial disc implantation for the following conditions:
- 1. Planned simultaneous, multilevel disc implantation;
- 2. Combined use of artificial disc and fusion (hybrid procedure);
- 3. Prior surgery at the level to be treated;
- 4. Previous fusion at the same or adjacent level;
- 5. Instability as defined by translation greater than 3 millimeters’ difference
between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;
- 6. Anatomical deformity such as ankylosing spondylitis or previous
fracture;
- 7. Ossification of the posterior longitudinal ligament (OPLL)
- 8. Severe spondylosis defined as greater than fifty (50) percent disc height
loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;
- 9. Rheumatoid arthritis or other autoimmune disease;
- 10. Presence of facet arthritis;
- 11. Sensitivity or allergy to implant materials
- 12. Active systemic or site infection;
- 13. Metabolic bone disease such as osteoporosis, osteopenia, or
osteomalacia; or
- 14. Malignancy of the cervical spine.
- b. Medicaid shall not cover spinal surgery if the sole indication is any one or
more of the following conditions:
- 1. Disc herniation;
- 2. Annular tears;
- 3. Degenerative disc disease;
- 4. Initial discectomy or laminectomy for neural structure decompression;
- 5. Facet syndrome; or
- 6. Back pain without any clear cause on imaging
Place of Service
Inpatient, Outpatient.
How to Submit
Please submit your request to Evolent
Resources
Spinal Surgeries
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
The provider(s) shall submit the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met
the specific criteria in this policy.
- c. if the Medicaid beneficiary is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
The provider shall submit the following information along with the request for surgery:
- a. A signed letter of medical necessity clearly documenting diagnosis and
date of symptom onset, the specific procedure(s) requested with CPT code(s) and disc level(s) indicated;
- b. Office notes, including a current history and physical exam within the past
thirty days;
- c. Detailed documentation of extent and response to conservative medical
management, including length of treatment, outcomes of any procedural interventions, medication use (including dose and frequency), participation in physical therapy or a home exercise program, and beneficiary acceptance of recommended lifestyle modifications;
- d. All radiology reports relevant to the surgical request. Imaging must be
read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede;
- e. Post-operative plan of care; and
- f. Medical clearance reports (as appropriate).
Limits
Single-level procedure only.
Covered only for cervical artificial disc implantation from C3-4 to C6-7.
Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.
Exclusions
Medicaid shall not cover artificial disc implantation for the following conditions:
- 1. Planned simultaneous, multilevel disc implantation;
- 2. Combined use of artificial disc and fusion (hybrid procedure);
- 3. Prior surgery at the level to be treated;
- 4. Previous fusion at the same or adjacent level;
- 5. Instability as defined by translation greater than 3 millimeters’ difference
between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;
- 6. Anatomical deformity such as ankylosing spondylitis or previous
fracture;
- 7. Ossification of the posterior longitudinal ligament (OPLL)
- 8. Severe spondylosis defined as greater than fifty (50) percent disc height
loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;
- 9. Rheumatoid arthritis or other autoimmune disease;
- 10. Presence of facet arthritis;
- 11. Sensitivity or allergy to implant materials
- 12. Active systemic or site infection;
- 13. Metabolic bone disease such as osteoporosis, osteopenia, or
osteomalacia; or
- 14. Malignancy of the cervical spine.
- b. Medicaid shall not cover spinal surgery if the sole indication is any one or
more of the following conditions:
- 1. Disc herniation;
- 2. Annular tears;
- 3. Degenerative disc disease;
- 4. Initial discectomy or laminectomy for neural structure decompression;
- 5. Facet syndrome; or
- 6. Back pain without any clear cause on imaging
Place of Service
Inpatient, Outpatient.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
Spinal Surgeries
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
See Evolent site for specific requirements
Reauthorization Guidelines
See Evolent site for specific requirements
Limits
Single-level procedure only.
Covered only for cervical artificial disc implantation from C3-4 to C6-7.
Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.
Exclusions
Medicaid shall not cover artificial disc implantation for the following conditions:
- 1. Planned simultaneous, multilevel disc implantation;
- 2. Combined use of artificial disc and fusion (hybrid procedure);
- 3. Prior surgery at the level to be treated;
- 4. Previous fusion at the same or adjacent level;
- 5. Instability as defined by translation greater than 3 millimeters’ difference
between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;
- 6. Anatomical deformity such as ankylosing spondylitis or previous
fracture;
- 7. Ossification of the posterior longitudinal ligament (OPLL)
- 8. Severe spondylosis defined as greater than fifty (50) percent disc height
loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;
- 9. Rheumatoid arthritis or other autoimmune disease;
- 10. Presence of facet arthritis;
- 11. Sensitivity or allergy to implant materials
- 12. Active systemic or site infection;
- 13. Metabolic bone disease such as osteoporosis, osteopenia, or
osteomalacia; or
- 14. Malignancy of the cervical spine.
- b. Medicaid shall not cover spinal surgery if the sole indication is any one or
more of the following conditions:
- 1. Disc herniation;
- 2. Annular tears;
- 3. Degenerative disc disease;
- 4. Initial discectomy or laminectomy for neural structure decompression;
- 5. Facet syndrome; or
- 6. Back pain without any clear cause on imaging
Place of Service
Inpatient, Outpatient.
How to Submit
Please submit your request to Evolent
Resources
Spinal Surgeries
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
See Evolent site for specific requirements
Reauthorization Guidelines
See Evolent site for specific requirements
Limits
Single-level procedure only.
Covered only for cervical artificial disc implantation from C3-4 to C6-7.
Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.
Exclusions
Medicaid shall not cover artificial disc implantation for the following conditions:
- 1. Planned simultaneous, multilevel disc implantation;
- 2. Combined use of artificial disc and fusion (hybrid procedure);
- 3. Prior surgery at the level to be treated;
- 4. Previous fusion at the same or adjacent level;
- 5. Instability as defined by translation greater than 3 millimeters’ difference
between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;
- 6. Anatomical deformity such as ankylosing spondylitis or previous
fracture;
- 7. Ossification of the posterior longitudinal ligament (OPLL)
- 8. Severe spondylosis defined as greater than fifty (50) percent disc height
loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;
- 9. Rheumatoid arthritis or other autoimmune disease;
- 10. Presence of facet arthritis;
- 11. Sensitivity or allergy to implant materials
- 12. Active systemic or site infection;
- 13. Metabolic bone disease such as osteoporosis, osteopenia, or
osteomalacia; or
- 14. Malignancy of the cervical spine.
- b. Medicaid shall not cover spinal surgery if the sole indication is any one or
more of the following conditions:
- 1. Disc herniation;
- 2. Annular tears;
- 3. Degenerative disc disease;
- 4. Initial discectomy or laminectomy for neural structure decompression;
- 5. Facet syndrome; or
- 6. Back pain without any clear cause on imaging
Place of Service
Inpatient, Outpatient.
How to Submit
Please submit your request to Evolent
Resources
Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (List separately in addi
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections.Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management.Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
The provider(s) shall submit the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met
the specific criteria in this policy.
The provider shall submit the following information along with the request for surgery:
- a. A signed letter of medical necessity clearly documenting diagnosis and
date of symptom onset, the specific procedure(s) requested with CPT code(s) and disc level(s) indicated;
- b. Office notes, including a current history and physical exam within the past
thirty days;
- c. Detailed documentation of extent and response to conservative medical
management, including length of treatment, outcomes of any procedural interventions, medication use (including dose and frequency), participation in physical therapy or a home exercise program, and beneficiary acceptance of recommended lifestyle modifications;
- d. All radiology reports relevant to the surgical request. Imaging must be
read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede;
- e. Post-operative plan of care; and
- f. Medical clearance reports (as appropriate).
- c. if the Medicaid beneficiary is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Exclusions
No posterior-cervical-fusion-specific non-coverage or exclusion language is stated in the provided packet. For beneficiaries under 21 years of age under EPSDT, Medicaid does not require coverage of any service, product, or procedure that is unsafe, ineffective, experimental or investigational, not medical in nature, or not generally recognized as an accepted method of medical practice or treatment.
Diagnosis Requirements
Coverage requires one or more of the following posterior-cervical-fusion-specific indications: - Concurrent stabilization with corpectomy, laminectomy, or another surgical procedure. - Symptomatic pseudoarthrosis from a prior fusion. - Subluxation or compression in rheumatoid arthritis. - Multilevel spondylotic myelopathy without kyphosis, evidenced by at least one of: clinical symptoms of myelopathy such as clumsiness of hands, urinary urgency, bowel or bladder incontinence, or frequent falls; clinical signs such as hyperreflexia, Hoffman sign, increased tone or spasticity, loss of thenar or hypothenar eminence, gait abnormality, or positive Babinski sign; or diagnostic imaging positive for cord compression from herniated disc or osteophyte. - Degenerative spondylosis with kyphosis causing spinal cord compression. - Unstable injuries consisting of atlas and axis fractures, disruption of posterior ligamentous structures, facet fractures with dislocation, bilateral locked facets, or central cord syndrome with multisegment injury.
- - Symptomatic cervical spondylosis with instability shown radiographically by at least one of: subluxation or translation of more than 3.5 millimeters on static lateral views or dynamic radiographs; sagittal plane angulation of more than 11 degrees between adjacent segments; or more than 4 millimeters of subluxation between the tips of the spinous processes on dynamic views. - Klippel-Feil syndrome. - Cervical instability in Down syndrome. - Cervical instability in skeletal dysplasia or connective tissue disorders.
- - Spinal tumor, abscess, or infection with associated cord compression or instability.
- - Other symptomatic instability or cord or root compression requiring posterior fusion, when both of the following are present: unresponsiveness to conservative care; and imaging study demonstrating corresponding pathologic anatomy.
Place of Service
Inpatient, Outpatient
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
Spinal Surgeries
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
The provider(s) shall submit the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met
the specific criteria in this policy.
- c. if the Medicaid beneficiary is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
The provider shall submit the following information along with the request for surgery:
- a. A signed letter of medical necessity clearly documenting diagnosis and
date of symptom onset, the specific procedure(s) requested with CPT code(s) and disc level(s) indicated;
- b. Office notes, including a current history and physical exam within the past
thirty days;
- c. Detailed documentation of extent and response to conservative medical
management, including length of treatment, outcomes of any procedural interventions, medication use (including dose and frequency), participation in physical therapy or a home exercise program, and beneficiary acceptance of recommended lifestyle modifications;
- d. All radiology reports relevant to the surgical request. Imaging must be
read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede;
- e. Post-operative plan of care; and
- f. Medical clearance reports (as appropriate).
Limits
Single-level procedure only.
Covered only for cervical artificial disc implantation from C3-4 to C6-7.
Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.
Exclusions
Medicaid shall not cover artificial disc implantation for the following conditions:
- 1. Planned simultaneous, multilevel disc implantation;
- 2. Combined use of artificial disc and fusion (hybrid procedure);
- 3. Prior surgery at the level to be treated;
- 4. Previous fusion at the same or adjacent level;
- 5. Instability as defined by translation greater than 3 millimeters’ difference
between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;
- 6. Anatomical deformity such as ankylosing spondylitis or previous
fracture;
- 7. Ossification of the posterior longitudinal ligament (OPLL)
- 8. Severe spondylosis defined as greater than fifty (50) percent disc height
loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;
- 9. Rheumatoid arthritis or other autoimmune disease;
- 10. Presence of facet arthritis;
- 11. Sensitivity or allergy to implant materials
- 12. Active systemic or site infection;
- 13. Metabolic bone disease such as osteoporosis, osteopenia, or
osteomalacia; or
- 14. Malignancy of the cervical spine.
- b. Medicaid shall not cover spinal surgery if the sole indication is any one or
more of the following conditions:
- 1. Disc herniation;
- 2. Annular tears;
- 3. Degenerative disc disease;
- 4. Initial discectomy or laminectomy for neural structure decompression;
- 5. Facet syndrome; or
- 6. Back pain without any clear cause on imaging
Place of Service
Inpatient, Outpatient.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
Spinal Surgeries
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
The provider(s) shall submit the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met
the specific criteria in this policy.
- c. if the Medicaid beneficiary is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
The provider shall submit the following information along with the request for surgery:
- a. A signed letter of medical necessity clearly documenting diagnosis and
date of symptom onset, the specific procedure(s) requested with CPT code(s) and disc level(s) indicated;
- b. Office notes, including a current history and physical exam within the past
thirty days;
- c. Detailed documentation of extent and response to conservative medical
management, including length of treatment, outcomes of any procedural interventions, medication use (including dose and frequency), participation in physical therapy or a home exercise program, and beneficiary acceptance of recommended lifestyle modifications;
- d. All radiology reports relevant to the surgical request. Imaging must be
read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede;
- e. Post-operative plan of care; and
- f. Medical clearance reports (as appropriate).
Limits
Single-level procedure only.
Covered only for cervical artificial disc implantation from C3-4 to C6-7.
Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.
Exclusions
Medicaid shall not cover artificial disc implantation for the following conditions:
- 1. Planned simultaneous, multilevel disc implantation;
- 2. Combined use of artificial disc and fusion (hybrid procedure);
- 3. Prior surgery at the level to be treated;
- 4. Previous fusion at the same or adjacent level;
- 5. Instability as defined by translation greater than 3 millimeters’ difference
between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;
- 6. Anatomical deformity such as ankylosing spondylitis or previous
fracture;
- 7. Ossification of the posterior longitudinal ligament (OPLL)
- 8. Severe spondylosis defined as greater than fifty (50) percent disc height
loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;
- 9. Rheumatoid arthritis or other autoimmune disease;
- 10. Presence of facet arthritis;
- 11. Sensitivity or allergy to implant materials
- 12. Active systemic or site infection;
- 13. Metabolic bone disease such as osteoporosis, osteopenia, or
osteomalacia; or
- 14. Malignancy of the cervical spine.
- b. Medicaid shall not cover spinal surgery if the sole indication is any one or
more of the following conditions:
- 1. Disc herniation;
- 2. Annular tears;
- 3. Degenerative disc disease;
- 4. Initial discectomy or laminectomy for neural structure decompression;
- 5. Facet syndrome; or
- 6. Back pain without any clear cause on imaging
Place of Service
Inpatient, Outpatient.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
Spinal Surgeries
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
See Evolent site for specific requirements
Reauthorization Guidelines
See Evolent site for specific requirements
Limits
Single-level procedure only.
Covered only for cervical artificial disc implantation from C3-4 to C6-7.
Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.
Exclusions
Medicaid shall not cover artificial disc implantation for the following conditions:
- 1. Planned simultaneous, multilevel disc implantation;
- 2. Combined use of artificial disc and fusion (hybrid procedure);
- 3. Prior surgery at the level to be treated;
- 4. Previous fusion at the same or adjacent level;
- 5. Instability as defined by translation greater than 3 millimeters’ difference
between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;
- 6. Anatomical deformity such as ankylosing spondylitis or previous
fracture;
- 7. Ossification of the posterior longitudinal ligament (OPLL)
- 8. Severe spondylosis defined as greater than fifty (50) percent disc height
loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;
- 9. Rheumatoid arthritis or other autoimmune disease;
- 10. Presence of facet arthritis;
- 11. Sensitivity or allergy to implant materials
- 12. Active systemic or site infection;
- 13. Metabolic bone disease such as osteoporosis, osteopenia, or
osteomalacia; or
- 14. Malignancy of the cervical spine.
- b. Medicaid shall not cover spinal surgery if the sole indication is any one or
more of the following conditions:
- 1. Disc herniation;
- 2. Annular tears;
- 3. Degenerative disc disease;
- 4. Initial discectomy or laminectomy for neural structure decompression;
- 5. Facet syndrome; or
- 6. Back pain without any clear cause on imaging
Place of Service
Inpatient, Outpatient.
How to Submit
Please submit your request to Evolent
Resources
Spinal Surgeries
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
The provider(s) shall submit the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met
the specific criteria in this policy.
- c. if the Medicaid beneficiary is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
The provider shall submit the following information along with the request for surgery:
- a. A signed letter of medical necessity clearly documenting diagnosis and
date of symptom onset, the specific procedure(s) requested with CPT code(s) and disc level(s) indicated;
- b. Office notes, including a current history and physical exam within the past
thirty days;
- c. Detailed documentation of extent and response to conservative medical
management, including length of treatment, outcomes of any procedural interventions, medication use (including dose and frequency), participation in physical therapy or a home exercise program, and beneficiary acceptance of recommended lifestyle modifications;
- d. All radiology reports relevant to the surgical request. Imaging must be
read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede;
- e. Post-operative plan of care; and
- f. Medical clearance reports (as appropriate).
Limits
Single-level procedure only.
Covered only for cervical artificial disc implantation from C3-4 to C6-7.
Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.
Exclusions
Medicaid shall not cover artificial disc implantation for the following conditions:
- 1. Planned simultaneous, multilevel disc implantation;
- 2. Combined use of artificial disc and fusion (hybrid procedure);
- 3. Prior surgery at the level to be treated;
- 4. Previous fusion at the same or adjacent level;
- 5. Instability as defined by translation greater than 3 millimeters’ difference
between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;
- 6. Anatomical deformity such as ankylosing spondylitis or previous
fracture;
- 7. Ossification of the posterior longitudinal ligament (OPLL)
- 8. Severe spondylosis defined as greater than fifty (50) percent disc height
loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;
- 9. Rheumatoid arthritis or other autoimmune disease;
- 10. Presence of facet arthritis;
- 11. Sensitivity or allergy to implant materials
- 12. Active systemic or site infection;
- 13. Metabolic bone disease such as osteoporosis, osteopenia, or
osteomalacia; or
- 14. Malignancy of the cervical spine.
- b. Medicaid shall not cover spinal surgery if the sole indication is any one or
more of the following conditions:
- 1. Disc herniation;
- 2. Annular tears;
- 3. Degenerative disc disease;
- 4. Initial discectomy or laminectomy for neural structure decompression;
- 5. Facet syndrome; or
- 6. Back pain without any clear cause on imaging
Place of Service
Inpatient, Outpatient.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
Spinal Surgeries
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
See Evolent site for specific requirements
Reauthorization Guidelines
See Evolent site for specific requirements
Limits
Single-level procedure only.
Covered only for cervical artificial disc implantation from C3-4 to C6-7.
Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.
Exclusions
Medicaid shall not cover artificial disc implantation for the following conditions:
- 1. Planned simultaneous, multilevel disc implantation;
- 2. Combined use of artificial disc and fusion (hybrid procedure);
- 3. Prior surgery at the level to be treated;
- 4. Previous fusion at the same or adjacent level;
- 5. Instability as defined by translation greater than 3 millimeters’ difference
between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;
- 6. Anatomical deformity such as ankylosing spondylitis or previous
fracture;
- 7. Ossification of the posterior longitudinal ligament (OPLL)
- 8. Severe spondylosis defined as greater than fifty (50) percent disc height
loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;
- 9. Rheumatoid arthritis or other autoimmune disease;
- 10. Presence of facet arthritis;
- 11. Sensitivity or allergy to implant materials
- 12. Active systemic or site infection;
- 13. Metabolic bone disease such as osteoporosis, osteopenia, or
osteomalacia; or
- 14. Malignancy of the cervical spine.
- b. Medicaid shall not cover spinal surgery if the sole indication is any one or
more of the following conditions:
- 1. Disc herniation;
- 2. Annular tears;
- 3. Degenerative disc disease;
- 4. Initial discectomy or laminectomy for neural structure decompression;
- 5. Facet syndrome; or
- 6. Back pain without any clear cause on imaging
Place of Service
Inpatient, Outpatient.
How to Submit
Please submit your request to Evolent
Resources
Spinal Surgeries
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
The provider(s) shall submit the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met
the specific criteria in this policy.
- c. if the Medicaid beneficiary is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
The provider shall submit the following information along with the request for surgery:
- a. A signed letter of medical necessity clearly documenting diagnosis and
date of symptom onset, the specific procedure(s) requested with CPT code(s) and disc level(s) indicated;
- b. Office notes, including a current history and physical exam within the past
thirty days;
- c. Detailed documentation of extent and response to conservative medical
management, including length of treatment, outcomes of any procedural interventions, medication use (including dose and frequency), participation in physical therapy or a home exercise program, and beneficiary acceptance of recommended lifestyle modifications;
- d. All radiology reports relevant to the surgical request. Imaging must be
read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede;
- e. Post-operative plan of care; and
- f. Medical clearance reports (as appropriate).
Limits
Single-level procedure only.
Covered only for cervical artificial disc implantation from C3-4 to C6-7.
Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.
Exclusions
Medicaid shall not cover artificial disc implantation for the following conditions:
- 1. Planned simultaneous, multilevel disc implantation;
- 2. Combined use of artificial disc and fusion (hybrid procedure);
- 3. Prior surgery at the level to be treated;
- 4. Previous fusion at the same or adjacent level;
- 5. Instability as defined by translation greater than 3 millimeters’ difference
between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;
- 6. Anatomical deformity such as ankylosing spondylitis or previous
fracture;
- 7. Ossification of the posterior longitudinal ligament (OPLL)
- 8. Severe spondylosis defined as greater than fifty (50) percent disc height
loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;
- 9. Rheumatoid arthritis or other autoimmune disease;
- 10. Presence of facet arthritis;
- 11. Sensitivity or allergy to implant materials
- 12. Active systemic or site infection;
- 13. Metabolic bone disease such as osteoporosis, osteopenia, or
osteomalacia; or
- 14. Malignancy of the cervical spine.
- b. Medicaid shall not cover spinal surgery if the sole indication is any one or
more of the following conditions:
- 1. Disc herniation;
- 2. Annular tears;
- 3. Degenerative disc disease;
- 4. Initial discectomy or laminectomy for neural structure decompression;
- 5. Facet syndrome; or
- 6. Back pain without any clear cause on imaging
Place of Service
Inpatient, Outpatient.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
Spinal Surgeries
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
See Evolent site for specific requirements
Reauthorization Guidelines
See Evolent site for specific requirements
Limits
Single-level procedure only.
Covered only for cervical artificial disc implantation from C3-4 to C6-7.
Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.
Exclusions
Medicaid shall not cover artificial disc implantation for the following conditions:
- 1. Planned simultaneous, multilevel disc implantation;
- 2. Combined use of artificial disc and fusion (hybrid procedure);
- 3. Prior surgery at the level to be treated;
- 4. Previous fusion at the same or adjacent level;
- 5. Instability as defined by translation greater than 3 millimeters’ difference
between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;
- 6. Anatomical deformity such as ankylosing spondylitis or previous
fracture;
- 7. Ossification of the posterior longitudinal ligament (OPLL)
- 8. Severe spondylosis defined as greater than fifty (50) percent disc height
loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;
- 9. Rheumatoid arthritis or other autoimmune disease;
- 10. Presence of facet arthritis;
- 11. Sensitivity or allergy to implant materials
- 12. Active systemic or site infection;
- 13. Metabolic bone disease such as osteoporosis, osteopenia, or
osteomalacia; or
- 14. Malignancy of the cervical spine.
- b. Medicaid shall not cover spinal surgery if the sole indication is any one or
more of the following conditions:
- 1. Disc herniation;
- 2. Annular tears;
- 3. Degenerative disc disease;
- 4. Initial discectomy or laminectomy for neural structure decompression;
- 5. Facet syndrome; or
- 6. Back pain without any clear cause on imaging
Place of Service
Inpatient, Outpatient.
How to Submit
Please submit your request to Evolent
Resources
Spinal Surgeries
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
See Evolent site for specific requirements
Reauthorization Guidelines
See Evolent site for specific requirements
Limits
Single-level procedure only.
Covered only for cervical artificial disc implantation from C3-4 to C6-7.
Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.
Exclusions
Medicaid shall not cover artificial disc implantation for the following conditions:
- 1. Planned simultaneous, multilevel disc implantation;
- 2. Combined use of artificial disc and fusion (hybrid procedure);
- 3. Prior surgery at the level to be treated;
- 4. Previous fusion at the same or adjacent level;
- 5. Instability as defined by translation greater than 3 millimeters’ difference
between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;
- 6. Anatomical deformity such as ankylosing spondylitis or previous
fracture;
- 7. Ossification of the posterior longitudinal ligament (OPLL)
- 8. Severe spondylosis defined as greater than fifty (50) percent disc height
loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;
- 9. Rheumatoid arthritis or other autoimmune disease;
- 10. Presence of facet arthritis;
- 11. Sensitivity or allergy to implant materials
- 12. Active systemic or site infection;
- 13. Metabolic bone disease such as osteoporosis, osteopenia, or
osteomalacia; or
- 14. Malignancy of the cervical spine.
- b. Medicaid shall not cover spinal surgery if the sole indication is any one or
more of the following conditions:
- 1. Disc herniation;
- 2. Annular tears;
- 3. Degenerative disc disease;
- 4. Initial discectomy or laminectomy for neural structure decompression;
- 5. Facet syndrome; or
- 6. Back pain without any clear cause on imaging
Place of Service
Inpatient, Outpatient.
How to Submit
Please submit your request to Evolent
Resources
Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; single vertebral segment (Lis
How to Submit
N/A - No authorization is required
Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; each additional vertebral seg
How to Submit
N/A - No authorization is required
Spinal Surgeries
There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.
Authorization Guidelines
The provider(s) shall submit the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met
the specific criteria in this policy.
- c. if the Medicaid beneficiary is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
The provider shall submit the following information along with the request for surgery:
- a. A signed letter of medical necessity clearly documenting diagnosis and
date of symptom onset, the specific procedure(s) requested with CPT code(s) and disc level(s) indicated;
- b. Office notes, including a current history and physical exam within the past
thirty days;
- c. Detailed documentation of extent and response to conservative medical
management, including length of treatment, outcomes of any procedural interventions, medication use (including dose and frequency), participation in physical therapy or a home exercise program, and beneficiary acceptance of recommended lifestyle modifications;
- d. All radiology reports relevant to the surgical request. Imaging must be
read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede;
- e. Post-operative plan of care; and
- f. Medical clearance reports (as appropriate).
Limits
Single-level procedure only.
Covered only for cervical artificial disc implantation from C3-4 to C6-7.
Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.
Exclusions
Medicaid shall not cover artificial disc implantation for the following conditions:
- 1. Planned simultaneous, multilevel disc implantation;
- 2. Combined use of artificial disc and fusion (hybrid procedure);
- 3. Prior surgery at the level to be treated;
- 4. Previous fusion at the same or adjacent level;
- 5. Instability as defined by translation greater than 3 millimeters’ difference
between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;
- 6. Anatomical deformity such as ankylosing spondylitis or previous
fracture;
- 7. Ossification of the posterior longitudinal ligament (OPLL)
- 8. Severe spondylosis defined as greater than fifty (50) percent disc height
loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;
- 9. Rheumatoid arthritis or other autoimmune disease;
- 10. Presence of facet arthritis;
- 11. Sensitivity or allergy to implant materials
- 12. Active systemic or site infection;
- 13. Metabolic bone disease such as osteoporosis, osteopenia, or
osteomalacia; or
- 14. Malignancy of the cervical spine.
- b. Medicaid shall not cover spinal surgery if the sole indication is any one or
more of the following conditions:
- 1. Disc herniation;
- 2. Annular tears;
- 3. Degenerative disc disease;
- 4. Initial discectomy or laminectomy for neural structure decompression;
- 5. Facet syndrome; or
- 6. Back pain without any clear cause on imaging
Place of Service
Inpatient, Outpatient.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Resources
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.