June 10, 2024
Cervical Fusion with Disc Removal and Prior Authorization Update
CURRENTLY:
MEDICAL NECESSITY: Currently includes several indications, persistent disability, daily pain, neck pain with associated symptoms, and failure to respond to conservative therapy.
DOCUMENTATION REQUIREMENTS: Clinical documentation related to pain, current H&P, office visit notes, etc., radiologic imaging, documentation related to conservative treatments tried, documentation related to how pain affects ADLs.
NEW RULE EFFECTIVE JULY 7, 2024
INDICATIONS: Three categories
REQUIREMENTS: (must meet ALL of the following)
- Moderate to severe arm pain (4 or more on VAS or equivalent) – present for a minimum of 12 weeks. Failure to respond to multimodal conservative treatment (as tolerated); AND
- Nerve compression that negatively impacts ADLS, AND
- All other sources of pain/neurological deficit have been excluded, AND
- Imaging that substantiates central, lateral recess or foraminal stenosis at the targeted level
See details in full LCD at:
FOR MORE INFORMATION: Register Here for our educational webinar that will be held on June 14, 2024.