Last Modified: 11/13/2024
Location: FL, PR, USVI
Business: Part A, Part B
This surgical procedure may relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness, and tingling. The procedure is accompanied by a fusion surgery to stabilize the spine.
Typically, there is an anterior approach to reach damaged vertebrae. An incision is made through the front of the neck, careful to avoid the esophagus, trachea, and thyroid. Retractors separate the intravertebral muscles. The disc space is cleaned out, removing the cartilaginous material above and below the vertebrae to be fused. The physician obtains and packs separately reportable graft material of iliac or other donor bone into the spaces. Traction is decreased to maintain the graft in its bed. The fascia is sutured, a drain is placed, and the incision is sutured.
Expedited requests are accepted if it is determined that a delay could seriously jeopardize the beneficiary’s life, health, or ability to regain maximum function. The documentation must include the reason for each expedited request. Please note procedure scheduling is not a valid reason for an expedited request. If the expedited request is valid, a decision will be rendered within two business days. If it is determined that the request does not substantiate the need for an expedited review, providers will be notified, and the request will return to the standard timeframe.
Effective for dates of service July 1, 2021, and after, hospital outpatient department (HOPD) providers will need to obtain
prior authorization (PA) for cervical fusion with disc removal if performed in a HOPD setting and billed with the follow CPT codes:
|
|
|
22551 |
Fusion of spine bones with removal of disc at upper spinal column, anterior approach, complex, initial. |
22552* |
Fusion of spine bones with removal of disc in upper spinal column below second vertebra of neck, anterior approach, each additional interspace. |
*Code 22552 is an add on code and it must be requested with 22551.
• Clear indication of what is being requested
• Relevant medical history, or general background information
• Physical examination findings
• Pertinent imaging reports, procedure reports, and/or progress notes
• Additional documentation that supports medical necessity for each indication
• Duration/character/location of pain, or myelopathy, or cervical spine deformities/instability
• Activities of daily living (ADL) limitations (when applicable)
• Failure to respond to multimodal conservative management (when applicable)
• Persistent or recurrent moderate or severe arm pain (4 or more on the visual analog scale (VAS) or equivalent) present for a minimum of 12 weeks within the current episode of neck pain with documented failure to respond to multimodal conservative management (as tolerated) in the absence of exceptional circumstances; and
• Nerve compression negatively impacts ADLs; and
• All other potential sources of pain/neurological deficit have been excluded; and
• Imaging (MRI or CT) evidence of central, lateral recess or foraminal stenosis at the level corresponding with clinical myotome signs or symptoms and including at least one of the following:
• Cervical degenerative disc disease as indicated by the presence of one or more of the following findings: herniated nucleus pulposus, narrowing of the intervertebral disc, disc osteophytes, facet hypertrophy, or synovial cysts
• Tumors (primary or metastatic)
• Post-infection radiographic findings
• Spinal instability as defined by subluxation or translation more than 3.5 mm on static lateral views or dynamic radiographs or sagittal plane angulation of more than 11 degrees between adjacent segments
• Persistent or recurrent moderate or severe arm pain (4 or more on the visual analog scale or equivalent) present for a minimum of 12 weeks within the episode of arm pain with documented failure to respond to multimodal conservative management (as tolerated) in the absence of exceptional circumstances; and
• Nerve compression that negatively impacts ADL; or
• Spastic gait, loss of manual dexterity, problems with sphincter control; and
• All other potential sources of pain/neurological deficit have been excluded; and
• Imaging (MRI or CT) evidence of central stenosis at the level corresponding with clinical signs or symptoms and including at least one of the following:
• Cervical degenerative disc disease as indicated by the presence of one or more of the following findings: herniated nucleus pulposus, narrowing of the intervertebral disc, disc osteophytes, facet hypertrophy, or synovial cysts
• Congenital short pedicles
• Tumors (primary or metastatic)
• Post infection radiographic findings
• Ossification of the posterior longitudinal ligament
• Spinal instability as defined by subluxation or translation more than 3.5 mm on static lateral views or dynamic radiographs or sagittal plane angulation of more than 11 degrees between adjacent segments
• Cord compression with or without increased cord signal
• Traumatic injuries including fractures, dislocations, facture-dislocations, or traumatic ligamentous disruption when:
• Fractures or dislocations are likely to result in spinal instability without neurological defects; or
• Fractures or dislocations associated with neurological defects are present at the affected level; or
• Instability is present
• Spinal tumors involving the spine or spinal canal when:
• Presence of malignant or benign tumors which have caused instability or neurologic deficit where treatment of the tumor will likely require stabilization of the spine; or
• Expected treatment of the tumor, whether by chemotherapy or radiation therapy or surgery will likely cause spinal instability or neurologic deficits; or
• Instability is present
• Infection involving the spine in the form of discitis, osteomyelitis, or epidural abscess when:
• Imaging or other studies (MRI, biopsy, bone aspirate) demonstrating infection; and
• Imaging evidence of vertebral body destruction or documentation that spinal debridement will cause vertebral instability; or
• Instability is present
• Deformities that include the cervical spine when:
• Cervical kyphosis associated with cord compression or atlantoaxial (C1-C2) subluxation or basilar invagination of the odontoid process into the foramen magnum; or subaxial (C2-T1) instability kyphosis, head drop syndrome, post-laminectomy deformity are present; or
• Symptomatic pseudarthrosis (non-union of prior fusion) with radiological demonstration (e.g., CT or MRI) of non-union of prior fusion (lack of bridging bone or abnormal motion at fused segment) after 12 months since fusion surgery or with radiographic evidence of hardware failure (fracture or displacement) is present; or
• Spinal instability is present after laminectomy; or
• Rheumatoid arthritis with associated instability is present; or
• Cervical degenerative spondylolisthesis with spinal instability (anterolisthesis/posterolisthesis) is present; and
• Substantial functional limitation is present such as severe neck pain, difficulty ambulating and decrease ability to perform ADLs or ability to maintain forward gaze; or
• Progression of deformity is present
The limitations below apply to symptomatic cervical nerve root impingement and cervical canal stenosis, except number 2 below*.
1. Isolated chronic axial cervical pain is not considered reasonable and necessary
2. Asymptomatic myelopathy is not considered reasonable and necessary (*cervical canal stenosis only)
3. Exceptions to conservative therapy policy requirements for:
• A diagnosis of cervical myelopathy:
• Class III or above; or
• Class IIIA – Objective weakness with long-tract signs; remains ambulatory
• Class IIIB – Objective weakness with long-tract signs; non-ambulatory and quadriparetic
• Progression of neurological deficits during the trial of conservative treatment
• A diagnosis of cervical radiculopathy:
• Progressive motor weakness; or
• Significant motor weakness that interferes with ADLs; or
• Severe radicular pain that limits ability to perform ADLs
• >7/10 pain on a VAS or equivalent; and
• Associated with confirmatory imaging (CT/MRI) and clinical radiological correlation
• Cauda Equina syndrome
All medical necessity criteria must be fulfilled as listed in the coverage requirements.
The A/B Medicare Administrative Contractor Prior Authorization Collaboration Workgroup developed this document. This joint effort ensures consistent communication and education throughout the nation on a variety of topics and assists the provider and physician community with information necessary to submit claims appropriately and receive proper payment in a timely manner.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
