HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-251-001
Topic:
Cervical Fusion with and without Discectomy
Section:
Surgery
Effective Date:
October 1, 2018
Issued Date:
October 1, 2018
Last Revision Date:
April 2018
Annual Review:
April 2018
 
 

Individuals refractory to conservative treatment (i.e., nonsteroidal anti-inflammatory drugs [NSAIDs], physical therapy), cervical spinal fusion (i.e., arthrodesis) is a surgical technique attempting to relieve spinal cord or nerve root pressure while stabilizing and eliminating the motion between the adjacent vertebral segments of the spine by fusing two or more cervical vertebrae. It is often performed in conjunction with anterior cervical discectomy (i.e., ACDF), during which a cervical herniated or degenerative disc may be removed or decompressed, while fusion is performed in order to stabilize the cervical segment. 

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

Initial Primary Cervical Discectomy and Fusion (ALL of the following)

Radiculopathy, Myelopathy or Myeloradiculopathy (Radiculopathy and/or Myelopathy required)

Radiculopathy (ALL of the following):

·         Subjective symptoms consistent with recent (within six (6) months) CT/MRI findings

o    Unremitting radiating pain to shoulder girdle and/or upper extremity with objective physical examination findings resulting in disability; or

o    Unremitting radicular arm pain/radiculitis without objective physical examination findings resulting in disability.

·         Objective physical examination findings: (ANY ONE of the following)

o    Neurologic deficit consistent with recent (within 6 months) CT/MRI findings: (ANY ONE of the following):

§  Dermatomal sensory deficit; or

§  Motor deficit (e.g., biceps, triceps weakness); or

§  Reflex changes; or

§  Shoulder Abduction Relief Sign; or

§  Nerve root tension sign (e.g. Spurlings maneuver); or

§  Radicular arm pain/Radiculitis without objective physical examination findings.

·         Failure of conservative treatment: (ANY TWO of the following)

o    Less than clinically meaningful improvement* from prescription strength analgesics, steroids, and/or NSAIDs for six (6) weeks;

o    Less than clinically meaningful improvement from a provider-directed program prescribed by a physical therapist, chiropractic provider, osteopathic or allopathic physician for six (6) weeks;

o    Less than clinically meaningful improvement from epidural steroid injections/selective nerve root block

·         Confirmatory Imaging

·         Recent (within six (6) months) CT/MRI identifies nerve root impingement caused by herniated disc(s) or osteophytes that correlates with the patient’s symptoms or physical findings

Myelopathy (ALL of the following):

·         Subjective Symptoms consistent with (ANY ONE of the following):

o    Upper/lower extremity weakness, numbness, or pain; or

o    Fine motor dysfunction (buttoning; handwriting; clumsiness of hands); or

o    Urinary urgency; or

o    New-onset bowel or bladder incontinence; or

o    Frequent falls

·         Objective physical examination findings (ANY TWO of the following):

o    Grip and release;

o    Ataxic gait;

o    Hyperreflexia;

o    Hoffmann sign;

o    Pathologic Babinski sign;

o    Balance insufficiency (tandem gait);

o    Inverted brachial radial reflex;

o    Increased tone or spasticity;

o    Clonus;

o    Myelopathic hand

·         Confirmatory Imaging

o    Recent (within six (6) months) CT/MRI findings that correlates with the patient’s symptoms or physical findings (ANY ONE of the following):

§  CT/MRI demonstrates spinal cord compression; or

§  CT/MRI identifies stenosis with or without myelomalacia.

·         Recent (within six (6) months) radiographs of the cervical spine including flexion/extension lateral views

·         No previous surgeries on the disc(s) involved with the exception of posterior laminoforaminotomies in a patient with myelopathy from ventral neurocompression

·         All major psychosocial and substance abuse issues have been addressed

Repeat Anterior Cervical Fusion at the same level

Criteria to be met: (ONE of the following)

·         Painful pseudoarthrosis unresponsive to 6 months of non-surgical care and

·         confirmatory imaging; or

·         Malposition or failure of the implant/structural bone graft; or

·         Recent (within 3 months) radiographs of the cervical spine including flexion/extension lateral views with evidence of implant/structural bone graft malposition or implant/structural bone graft failure;

Or ALL of the following:

Radiculopathy, Myelopathy or Myeloradiculopathy (Radiculopathy and/or Myelopathy required)

·         Radiculopathy secondary to herniated disc or osteophyte (ALL of the following):

o    Greater than six (6) weeks since the initial anterior cervical fusion surgery; and

o    Subjective symptoms consistent with recent (within three (3) months) CT/MRI findings:

§  Unremitting radiating pain to shoulder girdle and/or upper extremity with objective physical examination findings resulting in disability; or

§  Unremitting radicular arm pain/radiculitis without objective physical examination findings resulting in disability

o    Objective physical examination findings: (ANY ONE of the following)

§  Neurologic deficit consistent with recent (within 3 months) CT/MRI findings: [ANY ONE of the following]:

o    Dermatomal sensory deficit; or

o    Motor deficit (e.g., biceps, triceps weakness) ; or

o    Reflex changes; or

o    Radicular arm pain/radiculitis without objective physical examination findings

§  Shoulder Abduction Relief Sign

§  Nerve root tension sign (e.g. Spurlings maneuver)

o    Failure of conservative treatment: (ANY TWO of the following)

§  Less than clinically meaningful improvement from prescription strength analgesics, steroids, and/or NSAIDs for six (6) weeks

§  Less than clinically meaningful improvement from a provider-directed program prescribed by a physical therapist, chiropractic provider, osteopathic or allopathic physician for six (6) weeks

§  Less than clinically meaningful improvement from epidural steroid injections/selective nerve root block

o    Confirmatory Imaging (ANY ONE of the following):

§  Confirms evidence of neural structure compression (e.g. either retained disc material or a recurrent disc b. Recent (within 3 months) MRI with gadolinium/CT myelogram confirms evidence of neural structure compression (e.g., either retained disc material or a recurrent disc herniation)

§  Recent (within three (3) months) CT scan documenting pseudoarthrosis, no less than six (6) months after initial fusion

·         Myelopathy (ALL of the following):

o    Subjective Symptoms consistent with (ANY ONE of the following)

§  Upper/lower extremity weakness, numbness, or pain; or

§  Fine motor dysfunction (buttoning; handwriting; clumsiness of hands); or

§  Urinary urgency; or

§  New onset bowel or bladder incontinence; or

§  Frequent falls.

o    Objective physical examination findings (ANY TWO of the following)

§  Grip and release;

§  Ataxic gait;

§  Hyperreflexia;

§  Hoffmann sign;

§  Pathologic Babinski sign;

§  Balance insufficiency (tandem gait);

§  Inverted brachial radial reflex;

§  Increasedtone or spasticity;

§  Clonus;

§  Myelopathic hand.

o    Recent (within three (3) months) confirmatory MRI/CT findings (ANY ONE of the following):

§  MRI with gadolinium/CT myelogram confirms evidence of neural structure compression; or

§  MRI with gadolinium/CT myelogram identifies stenosis with or without myelomalacia; or

§  Recent (within 3 months) CT scan documenting pseudoarthrosis, no less than six (6) months after initial fusion

·         Initial relief of symptoms following previous disk decompression procedure at same level

·         All major psychosocial and substance abuse issues have been addressed herniation)

Adjacent Segment Disease: degenerative spinal segment adjacent to a previous decompression or fusion procedure (ALL of the following)

Radiculopathy, Myelopathy or Myeloradiculopathy (Radiculopathy and/or Myelopathy required)

·         Radiculopathy (ALL of the following):

o    Subjective symptoms consistent with recent (within 6 months) CT/MRI findings

§  Unremitting radiating pain to shoulder girdle and/or upper extremity with objective physical examination findings resulting in disability; or

§  Unremitting radicular arm pain/radiculitis without objective physical examination findings resulting in disability

o    Objective physical examination findings (ANY ONE of the following):

§  Neurologic deficit consistent with recent (within six (6) months) CT/MRI findings (ANY ONE of the following):

·         Dermatomal sensory deficit; or

·         Motor deficit (e.g., biceps, triceps weakness); or

·         Reflex changes; or

·         Shoulder Abduction Relief Sign; or

·         Nerve root tension sign (e.g. Spurlings maneuver); or

·         Radicular arm pain/Radiculitis without objective physical examination findings;

o    Failure of conservative treatment (ANY TWO of the following):

§  Less than clinically meaningful improvement* from prescription strength analgesics, steroids, and/or NSAIDs for six (6) weeks;

§  Less than clinically meaningful improvement from a provider-directed program prescribed by a physical therapist, chiropractic provider, osteopathic or allopathic physician for six (6) weeks;

§  Less than clinically meaningful improvement from epidural steroid injections/selective nerve root block.

o    Confirmatory Imaging

§  Recent (within six (6) months) CT/MRI identifies nerve root impingement caused by herniated disc(s) or osteophytes that correlates with the patient’s symptoms or physical findings

·         Myelopathy (ALL of the following):

o    Subjective Symptoms consistent with (ANY ONE of the following):

§  Upper/lower extremity weakness, numbness, or pain; or

§  Fine motor dysfunction (buttoning; handwriting; clumsiness of hands); or

§  Urinary urgency; or

§  New-onset bowel or bladder incontinence; or

§  Frequent falls.

o    Objective physical examination findings (ANY TWO of the following):

§  Grip and release;

§  Ataxic gait;

§  Hyperreflexia;

§  Hoffmann sign;

§  Pathologic Babinski sign;

§  Balance insufficiency (tandem gait);

§  Inverted brachial radial reflex;

§  Increased tone or spasticity;

§  Clonus;

§  Myelopathic hand.

o    Confirmatory Imaging:

§  Recent (within six (6) months) CT/MRI findings that correlates with the patient’s symptoms or physical findings (ANY ONE of the following):

·         CT/MRI demonstrates spinal cord compression; or

·         CT/MRI identifies stenosis with or without myelomalacia.

·         Recent (within six (6) months) radiographs of the cervical spine including flexion/extension lateral views demonstrating successful decompression and/or fusion at the adjacent level

·         No previous surgeries on the disc(s) involved

·         All major psychosocial and substance abuse issues have been addressed

·         Patient is a nonsmoker or has refrained from smoking for at least six (6) weeks prior to planned surgery. (Exception for patients with myelopathy)

Anterior Cervical Decompression and Fusion following failed cervical disc arthroplasty implant (Criteria to be met):

Recent (within three (3) months) imaging studies demonstrating failure of a cervical disc arthroplasty implant (i.e. subsidence, loosening, infection, dislocation, subluxation, vertebral body fracture, dislodgement)

Or ALL of the following:

Radiculopathy, Myelopathy or Myeloradiculopathy (Radiculopathy and/or Myelopathy required)

Radiculopathy (ALL of the following):

·         Subjective symptoms consistent with recent (within three (3) months) CT/MRI findings

o    Unremitting radiating pain to shoulder girdle and/or upper extremity with objective physical examination findings resulting in disability; or

o    Unremitting radicular arm pain/radiculitis without objective physical examination findings resulting in disability

·         Objective physical examination findings (Any one of the following):

o    Neurologic deficit consistent with recent (within three (3) months) CT/MRI findings (ANY ONE of the following):

§  Dermatomal sensory deficit; or

§  Motor deficit (e.g., biceps, triceps weakness); or

§  Reflex changes; or

§  Shoulder Abduction Relief Sign; or

§  Nerve root tension sign (e.g. Spurlings maneuver); or

§  Radicular arm pain/Radiculitis without objective physical examination findings.

·         Failure of conservative treatment: (ANY TWO of the following)

o    Less than clinically meaningful improvement* from prescription strength analgesics, steroids, and/or NSAIDs for six (6) weeks;

o    Less than clinically meaningful improvement from a provider-directed program prescribed by a physical therapist, chiropractic provider, osteopathic or allopathic physician for six (6) weeks;

o    Less than clinically meaningful improvement from epidural steroid injections/selective nerve root block.

·         Confirmatory Imaging

o    Recent (within three (3) months) CT/MRI identifies nerve root impingement caused by herniated disc(s) or osteophytes that correlates with the patient’s symptoms or physical findings

Myelopathy (ALL of the following):

·         Subjective Symptoms consistent with (ANY of the following):

o    Upper/lower extremity weakness, numbness, or pain; or

o    Fine motor dysfunction (buttoning; handwriting; clumsiness of hands); or

o    Urinary urgency; or

o    Newonset bowel or bladder incontinence;

o    Frequent falls.

·         Objective physical examination findings (ANY TWO of the following):

o    Grip and release;

o    Ataxic gait;

o    Hyperreflexia;

o    Hoffmann sign;

o    Pathologic Babinski sign;

o    Balance insufficiency (tandem gait);

o    Inverted brachial radial reflex;

o    Increased tone or spasticity;

o    Clonus;

o    Myelopathic hand.

·         Confirmatory Imaging:

o    Recent (within three (3) months) CT/MRI findings that correlates with the patient’s symptoms or physical findings (ANY ONE of the following):

§  CT/MRIdemonstrates spinal cord compression, or

§  CT/MRI identifies stenosis with or without myelomalacia.

o    Greater than six (6) months since the prior cervical disc arthroplasty procedure

o    All major psychosocial and substance abuse issues have been addressed

o    Patient is a nonsmoker or has refrained from smoking for at least six (6) weeks prior to planned surgery.*(Exception for patients with myelopathy)

Definitions:

Acceptable imaging modalities are CT scan, MRI and myelogram.Imaging must be performed and read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, nterpretations by the radiologist will supersede. Discography results will not be used as a determining factor of medical necessity for any requested procedures. Discographyuse is not endorsed. 

*Clinically meaningful improvement: Global assessment showing at least fifty percent (50%) improvement.

Nontraumatic Instability or Cervical Spondylosis (ALL of the following):

  • Confirmatory radiographic imaging (ANY ONE of the following):
  • Failure of conservative treatment (ANY TWO of the following)
    • Less than clinically meaningful improvement* from prescription strength analgesics, steroids, and/or NSAIDs for six (6) weeks;
    • Less than clinically meaningful improvement* from a provider-directed program prescribed by a physical therapist, chiropractic provider, osteopathic or allopathic physician for six (6) weeks;
  • All major psychosocial and substance abuse issues have been addressed
  •  
    • Flexion-Extension X-rays demonstrating instability; or
    • >3.5 mm sagittal plane translation; or
    • >20% sagittal plane translation of vertebral body width; or
    • >11 degrees relative sagittal plane angulation.

Limitations:

  • Requests for cervical fusion on a member with a history of two (2) or more cervical fusions requires Medical Review
  • Cervical fusion is not recommended for chronic non-specific cervical pain.
  • Assessment of arthrodesis and/or disc arthroplasty (i.e., “success”) via radiographic imaging is not attempted until at least 6 weeks following the procedure

 

*Clinically meaningful improvement: Global assessment showing at least 50% improvement

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Place of Service: Inpatient



The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

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