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OPD Procedure: Cervical Fusion with Disc Removal – Effective July 7, 2024

This surgical procedure may relieve cervical spinal cord or nerve root pressure and alleviate corresponding pain, weakness, and tingling. The procedure is accompanied by a fusion surgery to stabilize the spine.

Medical Necessity

The indications for cervical fusion surgery have been divided into three (3) categories:

Decompression of symptomatic cervical nerve root impingement
Decompression of symptomatic cervical canal stenosis
Decompression OR stabilization of the cervical spine

Indications and Documentation requirements

Cervical fusion surgery is considered reasonable and medically necessary in patients experiencing the broad requirements noted in each of the three categories below. The medical documentation should support the indication. For detailed information, please visit the CGS LCD on Cervical Fusion Surgery here: LCD - Cervical Fusion (L39741) (cms.gov)

Decompression of symptomatic cervical nerve root impingement is considered reasonable and medically necessary in patients experiencing ALL of the following:

Persistent or recurrent moderate to severe arm pain (4 or more on the VAS or equivalent) for a minimum of 12 weeks within the current episode of neck pain with documented failure to respond to conservative management, AND
Nerve compression that negatively impacts activities of daily living, AND
All other potential sources of pain/neurological deficit have been excluded, AND
MRI or CT imaging that provides evidence of central, lateral recess, or foraminal stenosis at the corresponding level and evidence of cervical degenerative disease

Decompression of symptomatic cervical canal stenosis is considered reasonable and medically necessary in patients experiencing one or more of the indications listed below:

Persistent or recurrent moderate to severe arm pain (4 or more on the VAS or equivalent) for a minimum of 12 weeks within the current episode of neck pain with documented failure to respond to conservative management, OR
Nerve compression that negatively impacts activities of daily living, OR
Spastic gait, loss of manual dexterity, problems with sphincter control AND
All other potential sources of pain/neurological deficit have been excluded AND
MRI or CT imaging that provides evidence of central stenosis at the corresponding level with clinical signs and symptoms that include at least one of the following:
- Congenital short pedicles, tumors, post infection findings, ossification of the posterior longitudinal ligament, spinal instability, cord compression with or without increased cord signal

Decompression or stabilization of the cervical spine is considered reasonable and medically necessary for the following indications:

Traumatic injuries, including factures or dislocations which are likely to result in spinal instability,
Spinal tumors involving the spine or spinal canal which have caused instability or where treatment of the tumor will likely require stabilization of the spine,
Infection involving the spine
- Requires imaging or other studies or documentation that spinal debridement will cause vertebral instability, or instability is present
Deformities that include the cervical spine

Prior Auth Request Form

Prior Authorization OPD: Cervical Fusion with Disc Removal