Aetna · Clinical coverage policy

Aetna Spinal Surgery: Laminectomy and Fusion coverage criteria

Aetna CPB 0743 covers spinal laminectomy/decompression, corpectomy, and cervical/thoracic/lumbar spinal fusion (plus laminoplasty, instrumentation removal, osteotomy, and pelvic fixation) only when documented imaging shows moderate-or-worse stenosis or true nerve/cord compression (or a specific structural condition such as fracture, tumor, infection, deformity, instability, or spondylolisthesis), the member has neural-compression symptoms limiting daily activities, and the member has failed the required course of conservative therapy (6 weeks or 3 months) unless an urgent indication such as myelopathy, cauda equina, severe/progressive weakness, or tumor/infection/fracture waives that wait; fusion additionally requires lab-documented nicotine cessation and HbA1c below 8% in diabetics unless urgent. Decompression/fusion for degenerative disc disease, mechanical axial pain without myelopathy, Bertolotti's syndrome, internal jugular vein stenosis, and indications not specifically listed are experimental/investigational or not covered.

Policy CPB 0743 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0743

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0743 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Spinal Surgery: Laminectomy and Fusion (CPT 22548), and what gets it denied?

Path
Aetna CPB 0743 covers spinal laminectomy/decompression, corpectomy, and cervical/thoracic/lumbar spinal fusion (plus laminoplasty, instrumentation removal, osteotomy, and pelvic fixation) only when documented imaging shows moderate-or-worse stenosis or true nerve/cord compression (or a specific structural condition such as fracture, tumor, infection, deformity, instability, or spondylolisthesis), the member has neural-compression symptoms limiting daily activities, and the member has failed the required course of conservative therapy (6 weeks or 3 months) unless an urgent indication such as myelopathy, cauda equina, severe/progressive weakness, or tumor/infection/fracture waives that wait; fusion additionally requires lab-documented nicotine cessation and HbA1c below 8% in diabetics unless urgent. Decompression/fusion for degenerative disc disease, mechanical axial pain without myelopathy, Bertolotti's syndrome, internal jugular vein stenosis, and indications not specifically listed are experimental/investigational or not covered. Coverage criteria include: Cervical laminectomy and/or anterior or posterior cervical discectomy and fusion for herniated discs or other causes of spinal cord or nerve root compression (osteophytic spurring, ligamentous hypertrophy) when ALL of the following: (1) all other reasonable sources of pain and/or neurological deficit have been ruled out, including but not limited to significant pathology at other spinal level(s) on the advanced imaging radiology report that is/are not part of the surgical request resulting in incomplete surgical planning; AND (2) member has signs/symptoms of neural compression (radiculopathy, neurogenic claudication, or myelopathy) at the treated levels; AND (3) advanced imaging (CT or MRI) indicates central, lateral recess, or foraminal stenosis graded moderate, moderate-to-severe, or severe (NOT mild or mild-to-moderate), or nerve root or spinal cord compression, at the level corresponding with the clinical findings; AND (4) member has failed at least 6 weeks of conservative therapy (WAIVED for the listed waiver indications); AND (5) member's activities of daily living are limited by symptoms of neural compression; Thoracic laminectomy and/or thoracic discectomy and fusion for herniated discs or other causes of thoracic nerve root compression (osteophytic spurring, ligamentous hypertrophy) when ALL of the following: (1) all other reasonable sources of pain/neurological deficit ruled out, including but not limited to significant pathology at other spinal level(s) on the advanced imaging radiology report that is/are not part of the surgical request resulting in incomplete surgical planning; AND (2) signs/symptoms of neural compression (radiculopathy, neurogenic claudication, myelopathy) at treated levels; AND (3) advanced imaging (CT/MRI) shows central/lateral recess/foraminal stenosis graded moderate, moderate-to-severe, or severe (not mild/mild-to-moderate), or nerve root or spinal cord compression, at the level corresponding with the clinical findings; AND (4) failed at least 6 weeks conservative therapy (WAIVED for waiver indications); AND (5) ADLs limited by symptoms of neural compression; Lumbar laminectomy for herniated disc when ALL of the following: (1) all other reasonable sources of pain/neurological deficit ruled out, including but not limited to significant pathology at other spinal level(s) on the advanced imaging radiology report that is/are not part of the surgical request resulting in incomplete surgical planning; AND (2) signs/symptoms of neural compression (radiculopathy, neurogenic extremity claudication, myelopathy) at treated levels; AND (3) advanced imaging (CT/MRI) shows central/lateral recess/foraminal stenosis graded moderate, moderate-to-severe, or severe (not mild/mild-to-moderate), or nerve root or spinal cord compression, at the level corresponding with the clinical findings; AND (4) failed at least 6 weeks conservative therapy (WAIVED for waiver indications); AND (5) ADLs limited by symptoms of neural compression; Cervical, thoracic, lumbar, or sacral laminectomy for ANY ONE of the following: spinal fracture with displaced fragments causing moderate-or-greater stenosis/nerve compression (imaging confirmed) with signs/symptoms of nerve compression; OR spinal infection confirmed by imaging; OR spinal tumor confirmed by imaging; OR epidural hematomas confirmed by imaging; OR synovial cysts, Tarlov cysts (perineurial/sacral meningeal cysts), or arachnoid cysts causing spinal cord or nerve root compression with unremitting pain after failed 6 weeks conservative therapy (WAIVED for waiver indications); OR spinal stenosis (central, lateral recess, or foraminal) graded moderate, moderate-to-severe, or severe (not mild/mild-to-moderate) with unremitting pain, confirmed by imaging at the level corresponding to neurological findings, after failed 6 weeks conservative therapy (WAIVED for waiver indications); OR repair of open spinal dysraphism, or radiographically demonstrated closed spinal dysraphism (including tethered cord) with significant signs/symptoms of lumbosacral dysfunction, or radiographically demonstrated closed spinal dysraphism in asymptomatic young children not yet toilet trained or not yet walking; OR other mass lesions confirmed by imaging upon individual case review; Lumbar decompression with or without discectomy for rapid progression of neurological impairment (foot drop, extremity weakness, saddle anesthesia, bladder/bowel dysfunction) with central, lateral recess, or foraminal stenosis (moderate or worse) confirmed by imaging at the levels corresponding to the neurologic findings; Vertebral corpectomy (removal of half or more of the vertebral body) for ANY of: tumors involving one or more vertebrae; OR greater than 50% compression fracture; OR retro-pulsed bone fragments; OR symptomatic moderate-or-greater central canal stenosis arising from vertebral body pathology (fracture, tumor, or congenital/acquired deformity); Cervical spinal fusion for cervical kyphosis associated with cord compression; Cervical spinal fusion for symptomatic pseudarthrosis (non-union of prior fusion) with radiological demonstration of non-union after 12 months have elapsed OR with hardware failure. NOTE: for pseudarthrosis without hardware failure or urgent need, member must be nicotine-free for 6 weeks prior, with lab documentation (nicotine level <=10 ng/ml) required; Cervical spinal fusion for burst fractures, fracture-dislocation with mechanical instability, locked facets, or unstable fractures confirmed by imaging; Cervical spinal fusion for spinal infection confirmed by imaging/biopsy; Cervical spinal fusion for spinal tumor (primary or metastatic) confirmed by imaging; Cervical spinal fusion for atlantoaxial (C1-C2) subluxation (e.g., associated with congenital anomaly, os odontoideum, or rheumatoid arthritis) noted as widening of the atlantodens interval greater than 3 mm; Cervical spinal fusion for basilar invagination of the odontoid process into the foramen magnum; Cervical spinal fusion for sub-axial (C2-T1) instability confirmed by imaging when BOTH: significant instability (sagittal plane translation of at least 3 mm on flexion/extension views OR relative sagittal plane angulation greater than 11 degrees); AND symptomatic unremitting pain that has failed 3 months of conservative management (WAIVED for waiver indications); Cervical spinal fusion as adjunct to excision of synovial cysts causing cord/nerve compression with unremitting pain after failed 6 weeks conservative therapy (WAIVED for waiver indications or progressive deficit); Cervical spinal fusion for clinically significant deformity of the spine (kyphosis, head-drop syndrome, post-laminectomy deformity) after failed 6 weeks conservative therapy and nicotine-free 6 weeks, when ANY of: deformity prohibits forward gaze; OR associated with severe neck pain, difficulty ambulating, AND interference with ADL; OR documented progression of deformity; Cervical spinal fusion for occipito-cervical instability (seen in Down's syndrome, the mucopolysaccharidoses, and rheumatoid arthritis; occipito-cervical dislocation/instability also seen after high-energy trauma). A Power's ratio greater than 1.0 raises concern for occipito-cervical dislocation, and a basion-dens (BD) or basion-posterior axial interval (BAI) greater than 12 mm suggests occipito-cervical dissociation/instability (BD plus BAI is the Harris method, best measured on CT). Medically necessary in traumatic cases with documented instability via Harris measurements and ligamentous disruption; also for congenital/acquired cases (e.g., Down's syndrome, mucopolysaccharidoses, rheumatoid arthritis) with cord compression at the occipito-cervical junction. NOTE: when there is signal change in some ligaments only without abnormalities in Power's ratio, BDI, BAI-BDI and X-line, conservative management with stabilization may be the appropriate first-line treatment; Thoracic spinal fusion for scoliosis confirmed by imaging with Cobb angle greater than 40 degrees in skeletally immature children/adolescents, OR Cobb angle greater than 50 degrees associated with functional impairment in skeletally mature adults, that has failed 3 months of conservative management; Thoracic spinal fusion for thoracic kyphosis resulting in spinal cord compression, OR kyphotic curve greater than 75 degrees refractory to bracing, that has failed 3 months of conservative management; Thoracic spinal fusion for thoracic pseudarthrosis (absence of bridging bone connecting the vertebrae, or movement of vertebrae at the site of prior attempted arthrodesis on dynamic radiographs) after 12 months have elapsed OR with hardware failure. NOTE: nicotine-free 6 weeks required for non-urgent cases, with lab documentation required; Thoracic spinal fusion for burst fractures, fracture-dislocation with mechanical instability, locked facets, or unstable fractures confirmed by imaging; Thoracic spinal fusion for spinal infection confirmed by imaging/biopsy; Thoracic spinal fusion for spinal tumor (primary or metastatic) confirmed by imaging; Thoracic spinal fusion for spondylolisthesis with segmental instability confirmed by imaging (CT or MRI) when BOTH: significant spondylolisthesis grades II, III, IV, or V; AND symptomatic unremitting pain that has failed 6 weeks of conservative management (WAIVED for waiver indications); Thoracic spinal fusion for spinal stenosis meeting thoracic decompression criteria AND ANY of: decompression in an area of segmental instability on flexion/extension radiographs; OR decompression coincides with any degree of anterolisthesis (grades I-V); OR decompression creates iatrogenic instability by disruption of the posterior elements (facet excision greater than 50% bilaterally or complete facet excision); Lumbar spinal fusion for adult scoliosis confirmed by imaging with Cobb angle greater than 50 degrees associated with functional impairment in skeletally mature adults, that has failed 3 months of conservative management; Lumbar spinal fusion for lumbar pseudarthrosis (absence of bridging bone connecting the vertebrae, or movement of vertebrae at the site of prior attempted arthrodesis on dynamic radiographs) after 12 months have elapsed OR with hardware failure. NOTE: nicotine-free 6 weeks required, with lab documentation (nicotine level <=10 ng/ml) required; Lumbar spinal fusion for iatrogenic or degenerative flatback syndrome (back pain, stooped posture, and limitation of forward gaze) with significant sagittal imbalance that has failed 3 months of conservative management, when fusion is performed with spinal osteotomy and/or lordotic anterior interbody implants. Significant sagittal imbalance exists when ANY: offset >5 cm between the sagittal vertebral axis and posterior superior S1; OR pelvic tilt >20 degrees; OR lumbar lordosis to pelvic incidence mismatch >=10 degrees; Lumbar spinal fusion for spinal fracture causing instability or neural element compromise/compression, spinal dislocation (with mechanical instability), locked facets, or fracture with displaced fracture fragment confirmed by imaging. EXCLUDED: pars defects/fractures, subacute/chronic compression fractures, compression fractures without retropulsion causing significant stenosis, chronic stable odontoid fractures, spinous process fractures, transverse process fractures, and stable isolated pedicle fractures; Lumbar spinal fusion for pars defects (fractures) without significant instability (for spondylolisthesis use the spondylolisthesis criterion) with disc degeneration at the surgical level in members under 18 years who have failed >=6 months conservative management including bracing AND >=6 weeks formal in-person physical therapy within the past year; Lumbar spinal fusion for spinal infection confirmed by imaging/biopsy; Lumbar spinal fusion for spinal tumor confirmed by imaging; Lumbar spinal fusion for spondylolisthesis with segmental instability confirmed by imaging (CT or MRI) with associated symptomatic unremitting low back pain, radiculopathy, or neurogenic claudication, when EITHER: radiographic documentation of significant spondylolisthesis grades II, III, IV, or V with failure of 6 weeks conservative management (WAIVED for waiver indications); OR radiographic documentation of dynamic instability of at least 4 mm translation or 10 degrees of angular motion on dynamic imaging with failure of 6 weeks conservative management (WAIVED for waiver indications); Lumbar spinal fusion for spinal stenosis meeting lumbar decompression criteria AND ANY of: decompression in an area of segmental instability on flexion/extension radiographs; OR decompression coincides with any degree of anterolisthesis (grades I-V); OR intraoperative iatrogenic instability from the initial primary laminectomy/discectomy; OR revision decompression creating iatrogenic instability by anterior/posterior disruption (facet excision greater than 50% bilaterally or complete facet excision); Spinal surgery in patients with prior spinal surgery when the applicable laminectomy/decompression/corpectomy medical-necessity criteria are met; Removal of large anterior cervical osteophytes that are causing dysphagia (with or without anterior fusion), where the osteophytes are deemed the cause by an ENT specialist or certified speech therapist; Cervical laminoplasty (laminaplasty) for members with at least moderate cervical spinal stenosis at multiple (>=2) levels where 2 or more vertebral segments are to be decompressed, when ALL: other reasonable sources of pain/neurologic deficit ruled out; AND signs/symptoms of spinal cord compression (myelopathy) at the treated levels; AND imaging shows central stenosis (moderate or greater) or spinal cord compression at corresponding levels; AND imaging shows <=3 mm of motion on cervical flexion/extension x-rays and no cervical kyphosis; AND failed >=6 weeks conservative therapy (WAIVED for waiver indications); Exploration of spinal fusion (CPT 22830) separately reimbursable when criteria for fusion for pseudarthrosis are met but intra-operative findings reveal solid fusion with no additional procedures. NOTE: incidental when performed in the same anatomic region as other procedures; cannot combine with other spinal procedures in the same area; Removal of posterior spinal instrumentation when ANY of: neurologic complication related to its ongoing presence (e.g., screw compressing a nerve root causing radiculopathy); OR new pain or protruding mass at the operative site after significant trauma; OR severe back/neck pain after the fusion has healed related to the instrumentation, with failed conservative management including >=6 weeks formal in-person physical therapy in the past year; OR spinal infection; OR symptomatic rod, hook, or screw migration, dislodgment, or breakage; OR vascular complications from the instrumentation; OR further approved surgery requiring removal. NOTE: removal necessary for an approved fusion is not reimbursable when new instrumentation is inserted at the previously instrumented levels; Removal of anterior spinal instrumentation when ANY of: further approved surgery requiring removal; OR neurologic or vascular complication from its ongoing presence; OR instrumentation failure/migration risking neurologic/vascular complications; OR spinal infection; OR dysphagia from esophageal compression by anterior cervical implants (confirmed by ENT/barium swallow). NOTE: removal for an approved fusion is not reimbursable with new instrumentation at the previously instrumented levels; Thoracolumbar osteotomy only when there is a significant deformity that meets criteria described elsewhere in this CPB. NOTE: laminectomies and TLIFs cannot be approved separately when combined with osteotomies; Excision of a portion of the bony spine (portion of the vertebral body, facets, or lamina) for a bony lesion when ALL: a bony lesion is documented on a formal advanced imaging report (CT or MRI); AND additional radiographic investigation completed to define the lesion if appropriate (angiogram, SPECT, PET); AND bone biopsy performed and pathology available; AND pathology documents a lesion for which medical literature supports excision and other treatments were considered; AND removal of the entire bone at that level is not indicated; Pelvic fixation where criteria for lumbar fusion are met, for ANY of: fusion from L2 or above to the sacrum; OR multi-level fusion with non-union or sacral insufficiency fracture; OR fusion of high-grade lumbosacral spondylolisthesis at L5/S1 (Grade 3 or higher); Computer-assisted surgical navigation (stereotaxic navigation) approvable if fusion implants are being placed during surgery on the spinal column, with documented stereotaxic system identification, registration, imaging verification, and intraoperative use (NOT approvable during routine decompression, with possible exceptions for tumor decompressions); Conservative management (footnote requirement): conservative measures must be recent (within the past year) and include patient education, active in-person physical therapy (not home/virtual), medications (NSAIDs, acetaminophen, tricyclic antidepressants), and identification/management of associated anxiety or depression; member must participate the full duration (6 weeks or 3 months depending on indication); confirmed by PT notes or member claims history; Waiver of the conservative-management requirement applies when ANY of: spinal cord compression (excludes nerve root compression); OR stenosis causing cauda equina syndrome; OR stenosis causing myelopathy (cervical/thoracic only, not lumbar); OR stenosis causing severe weakness of muscle(s) innervated at the requested surgical level(s) graded 4-minus or less on the MRC scale (4-minus strength describes muscle activation that is beyond antigravity (3/5) and produces motion against only slight resistance and fails against moderate resistance); OR progressive neurological deficit on serial examinations by the same surgeon; OR severe stenosis with instability (dynamic excursion on flexion/extension or supine-to-standing) when fusion is requested; OR a physical therapist discharge note documenting lack of utility of further therapy due to the member's inability to adapt to a tolerable treatment plan from exceptional pain; Spinal fusion prerequisite: member should be nicotine-free (including smoking, tobacco products, and nicotine replacement therapy) for at least 6 weeks prior to surgery; for recent (within a year) nicotine use, documentation of cessation should include a lab report (not surgeon summary) showing blood and/or urine nicotine <=10 ng/ml (or urinary cotinine <=10 ng/ml) drawn within 6 weeks prior to surgery -- UNLESS there is an indication (e.g., myelopathy, cauda equina syndrome), severe weakness (4-minus or less on MRC scale) or progressive weakness, or an associated infection/tumor and/or fracture; Spinal fusion prerequisite: if the member is diabetic, hemoglobin A1C (HbA1c) should be less than 8 percent within 3 months prior to surgery, unless there is an urgent indication for surgery (e.g., myelopathy, cauda equina syndrome), severe weakness (4-minus or less on MRC scale) or progressive weakness, or an associated infection/tumor and/or acute fracture; Elective laminectomy prerequisite: if the member is diabetic, HbA1c should be less than 8 percent within 3 months prior to surgery, unless there is an indication (e.g., myelopathy, cauda equina syndrome), severe weakness (4-minus or less on MRC scale) or progressive weakness, or an associated infection/tumor and/or acute fracture; Stenosis grading definitions (for purposes of this policy): CENTRAL stenosis grades -- normal or mild stenosis (ligamentum flavum hypertrophy and/or osteophytes and/or disk bulging without significant narrowing of the central spinal canal); moderate stenosis (central spinal canal narrowed such that there is minimal spinal fluid visible in the dural sac); severe stenosis (central spinal canal narrowed with only a faint amount of spinal fluid or no fluid in the dural sac; cord morphological change is a sign of severe stenosis). FORAMINAL stenosis grades -- mild (some perineural fat remains visible around the nerve root); moderate (minimal perineural fat but no morphological changes); severe (nerve root morphological change, not just nerve root displacement). Any nerve root or spinal cord compression meets criteria regardless of the degree of stenosis on the imaging report; terms such as mass effect, impingement, abutment, effacement, indentation, flattening or displacement do not substitute for compression.. Applies to 44 codes: 22548, 22551, 22552, 22554, 22590, 22595, 22600, 22612, 22614, 22630, 22632, 22633, 22634, 63001, 63003, 63005, 63012, 63015, 63016, 63017, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63055, 63056, 63057, 63075, 63076, 63077, 63078, 22840, 22842, 22845, 22853, 22854.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Medical records must document that a physical examination, including a neurologic examination, has been performed by or reviewed by the operating surgeon; Advanced imaging studies (CT, MRI, myelogram) are required prior to any spinal surgery; imaging must be performed within the past year, or after the onset of the current constellation of symptoms or any relevant surgical procedures, whichever is sooner; The official written report of advanced imaging studies is used; if the operating surgeon disagrees with the official written report, the surgeon must document the disagreement, discuss it with the interpreter, and obtain a written addendum to the official report indicating agreement or disagreement; Conservative management / physical therapy participation must be documented by physical therapy notes or member claims history; For pseudarthrosis cases without hardware failure or urgent need (and for recent nicotine users prior to fusion): a lab report (not a surgeon summary) showing blood/urine nicotine <=10 ng/ml (or urinary cotinine <=10 ng/ml) drawn within 6 weeks prior to surgery; For diabetic members: HbA1c lab result (less than 8 percent within 3 months prior to surgery) for elective laminectomy/fusion unless an urgent/qualifying indication applies; For waiver of conservative management based on exceptional pain: a physical therapist discharge note documenting lack of utility of further therapy due to the member's inability to adapt to a tolerable treatment plan; For anterior cervical osteophyte removal causing dysphagia: documentation that an ENT specialist or certified speech therapist deemed the osteophytes the cause (for anterior instrumentation removal due to dysphagia, ENT confirmation and/or barium swallow); For excision of a bony spine lesion: formal advanced imaging report (CT/MRI) documenting the lesion, appropriate additional radiographic investigation (angiogram/SPECT/PET) if indicated, and a bone biopsy with available pathology; For computer-assisted surgical navigation: documentation identifying the stereotaxic system, registration, imaging verification, and its intraoperative use.
Trap
Policy exclusions and limitations: Experimental, investigational, or unproven (for all indications not listed as medically necessary): avulsion of spinal nerves; Experimental, investigational, or unproven: cervical, thoracic, and lumbar laminectomy and/or fusion for indications not listed as medically necessary; Experimental, investigational, or unproven: cervical laminoplasty for treatment of cervical kyphosis, for mechanical axial neck pain (cervical strain) without myelopathy, and for all other indications not listed as medically necessary; Experimental, investigational, or unproven: inter-laminar lumbar instrumented fusion (ILIF) and the Coflex-F implant for lumbar fusion (see CPB 0016); see also CPB 0772 - Axial Lumbar Interbody Fusion (AxiaLIF); Experimental, investigational, or unproven: computer-assisted surgical navigation for laminectomies. NOTE: robotic assistance is considered integral to the primary procedure and not separately reimbursed; Experimental, investigational, or unproven: lumbar spinal fusion for degenerative disc disease and all other indications not listed as medically necessary; Experimental, investigational, or unproven: occipito-cervical fusion/stabilization not listed as medically necessary; Experimental, investigational, or unproven: removal of the C1 tubercle or transverse process, or cervical laminectomy, for treatment of internal jugular vein stenosis; Experimental, investigational, or unproven: surgery for Bertolotti's syndrome (fusion or resection of the lumbosacral articulation); Not medically necessary: paraspinal muscle flap closure or tissue transfer (by a plastic or other surgeon, including the operating surgeon) at the time of spinal surgeries, as wound closure is included in the surgery and not separately reimbursable, and there is no literature evidence that particular methods of wound closure produce improved outcomes; Not covered: cervical laminoplasty for cervical kyphosis; Not covered: cervical laminoplasty for other/unspecified cervical disc disorders; Not covered: cervical laminoplasty for cervical spondylosis with myelopathy; Not covered: cervical laminoplasty for cervical spondylosis without myelopathy; Not covered: cervical laminoplasty for cervical disc disorder with radiculopathy; Not covered: cervical laminoplasty for other cervical disc displacement; Not covered: cervical laminoplasty for other cervical disc degeneration; Not covered: cervical laminoplasty for cervicocranial syndrome; Not covered: cervical laminoplasty for cervicobrachial syndrome; Not covered: cervical laminoplasty for other specified dorsopathies; Not covered: cervical laminoplasty for cervicalgia; Not covered: cervical laminoplasty for occipital neuralgia; Not covered: cervical laminoplasty for other/unspecified dorsalgia; Not covered: cervical laminoplasty for contracture of muscle; Not covered: cervical laminoplasty for postlaminectomy syndrome; Not covered: cervical laminoplasty for subluxation complex (cervical); Not covered: cervical laminoplasty for congenital cervical kyphosis; Not covered: cervical laminoplasty for subluxation/dislocation of cervical vertebra; Not covered: cervical laminoplasty for sprain/strain of cervical spine ligaments; Not covered: cervical, thoracic, lumbar/sacral laminectomy for internal jugular vein stenosis; Not covered: lumbar spinal fusion for other thoracic/thoracolumbar/lumbosacral intervertebral disc degeneration; Not covered: lumbar spinal fusion for Bertolotti's syndrome; Excluded indications for lumbar fusion for spinal fracture: pars defects/fractures, subacute/chronic compression fractures, compression fractures without retropulsion causing significant stenosis, chronic stable odontoid fractures, spinous process fractures, transverse process fractures, and stable isolated pedicle fractures. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0743 — Spinal Surgery: Laminectomy and Fusion

Coverage criteria

  • Cervical laminectomy and/or anterior or posterior cervical discectomy and fusion for herniated discs or other causes of spinal cord or nerve root compression (osteophytic spurring, ligamentous hypertrophy) when ALL of the following: (1) all other reasonable sources of pain and/or neurological deficit have been ruled out, including but not limited to significant pathology at other spinal level(s) on the advanced imaging radiology report that is/are not part of the surgical request resulting in incomplete surgical planning; AND (2) member has signs/symptoms of neural compression (radiculopathy, neurogenic claudication, or myelopathy) at the treated levels; AND (3) advanced imaging (CT or MRI) indicates central, lateral recess, or foraminal stenosis graded moderate, moderate-to-severe, or severe (NOT mild or mild-to-moderate), or nerve root or spinal cord compression, at the level corresponding with the clinical findings; AND (4) member has failed at least 6 weeks of conservative therapy (WAIVED for the listed waiver indications); AND (5) member's activities of daily living are limited by symptoms of neural compression
  • Thoracic laminectomy and/or thoracic discectomy and fusion for herniated discs or other causes of thoracic nerve root compression (osteophytic spurring, ligamentous hypertrophy) when ALL of the following: (1) all other reasonable sources of pain/neurological deficit ruled out, including but not limited to significant pathology at other spinal level(s) on the advanced imaging radiology report that is/are not part of the surgical request resulting in incomplete surgical planning; AND (2) signs/symptoms of neural compression (radiculopathy, neurogenic claudication, myelopathy) at treated levels; AND (3) advanced imaging (CT/MRI) shows central/lateral recess/foraminal stenosis graded moderate, moderate-to-severe, or severe (not mild/mild-to-moderate), or nerve root or spinal cord compression, at the level corresponding with the clinical findings; AND (4) failed at least 6 weeks conservative therapy (WAIVED for waiver indications); AND (5) ADLs limited by symptoms of neural compression
  • Lumbar laminectomy for herniated disc when ALL of the following: (1) all other reasonable sources of pain/neurological deficit ruled out, including but not limited to significant pathology at other spinal level(s) on the advanced imaging radiology report that is/are not part of the surgical request resulting in incomplete surgical planning; AND (2) signs/symptoms of neural compression (radiculopathy, neurogenic extremity claudication, myelopathy) at treated levels; AND (3) advanced imaging (CT/MRI) shows central/lateral recess/foraminal stenosis graded moderate, moderate-to-severe, or severe (not mild/mild-to-moderate), or nerve root or spinal cord compression, at the level corresponding with the clinical findings; AND (4) failed at least 6 weeks conservative therapy (WAIVED for waiver indications); AND (5) ADLs limited by symptoms of neural compression
  • Cervical, thoracic, lumbar, or sacral laminectomy for ANY ONE of the following: spinal fracture with displaced fragments causing moderate-or-greater stenosis/nerve compression (imaging confirmed) with signs/symptoms of nerve compression; OR spinal infection confirmed by imaging; OR spinal tumor confirmed by imaging; OR epidural hematomas confirmed by imaging; OR synovial cysts, Tarlov cysts (perineurial/sacral meningeal cysts), or arachnoid cysts causing spinal cord or nerve root compression with unremitting pain after failed 6 weeks conservative therapy (WAIVED for waiver indications); OR spinal stenosis (central, lateral recess, or foraminal) graded moderate, moderate-to-severe, or severe (not mild/mild-to-moderate) with unremitting pain, confirmed by imaging at the level corresponding to neurological findings, after failed 6 weeks conservative therapy (WAIVED for waiver indications); OR repair of open spinal dysraphism, or radiographically demonstrated closed spinal dysraphism (including tethered cord) with significant signs/symptoms of lumbosacral dysfunction, or radiographically demonstrated closed spinal dysraphism in asymptomatic young children not yet toilet trained or not yet walking; OR other mass lesions confirmed by imaging upon individual case review
  • Lumbar decompression with or without discectomy for rapid progression of neurological impairment (foot drop, extremity weakness, saddle anesthesia, bladder/bowel dysfunction) with central, lateral recess, or foraminal stenosis (moderate or worse) confirmed by imaging at the levels corresponding to the neurologic findings
  • Vertebral corpectomy (removal of half or more of the vertebral body) for ANY of: tumors involving one or more vertebrae; OR greater than 50% compression fracture; OR retro-pulsed bone fragments; OR symptomatic moderate-or-greater central canal stenosis arising from vertebral body pathology (fracture, tumor, or congenital/acquired deformity)
  • Cervical spinal fusion for cervical kyphosis associated with cord compression
  • Cervical spinal fusion for symptomatic pseudarthrosis (non-union of prior fusion) with radiological demonstration of non-union after 12 months have elapsed OR with hardware failure. NOTE: for pseudarthrosis without hardware failure or urgent need, member must be nicotine-free for 6 weeks prior, with lab documentation (nicotine level <=10 ng/ml) required
  • Cervical spinal fusion for burst fractures, fracture-dislocation with mechanical instability, locked facets, or unstable fractures confirmed by imaging
  • Cervical spinal fusion for spinal infection confirmed by imaging/biopsy
  • Cervical spinal fusion for spinal tumor (primary or metastatic) confirmed by imaging
  • Cervical spinal fusion for atlantoaxial (C1-C2) subluxation (e.g., associated with congenital anomaly, os odontoideum, or rheumatoid arthritis) noted as widening of the atlantodens interval greater than 3 mm
  • Cervical spinal fusion for basilar invagination of the odontoid process into the foramen magnum
  • Cervical spinal fusion for sub-axial (C2-T1) instability confirmed by imaging when BOTH: significant instability (sagittal plane translation of at least 3 mm on flexion/extension views OR relative sagittal plane angulation greater than 11 degrees); AND symptomatic unremitting pain that has failed 3 months of conservative management (WAIVED for waiver indications)
  • Cervical spinal fusion as adjunct to excision of synovial cysts causing cord/nerve compression with unremitting pain after failed 6 weeks conservative therapy (WAIVED for waiver indications or progressive deficit)
  • Cervical spinal fusion for clinically significant deformity of the spine (kyphosis, head-drop syndrome, post-laminectomy deformity) after failed 6 weeks conservative therapy and nicotine-free 6 weeks, when ANY of: deformity prohibits forward gaze; OR associated with severe neck pain, difficulty ambulating, AND interference with ADL; OR documented progression of deformity
  • Cervical spinal fusion for occipito-cervical instability (seen in Down's syndrome, the mucopolysaccharidoses, and rheumatoid arthritis; occipito-cervical dislocation/instability also seen after high-energy trauma). A Power's ratio greater than 1.0 raises concern for occipito-cervical dislocation, and a basion-dens (BD) or basion-posterior axial interval (BAI) greater than 12 mm suggests occipito-cervical dissociation/instability (BD plus BAI is the Harris method, best measured on CT). Medically necessary in traumatic cases with documented instability via Harris measurements and ligamentous disruption; also for congenital/acquired cases (e.g., Down's syndrome, mucopolysaccharidoses, rheumatoid arthritis) with cord compression at the occipito-cervical junction. NOTE: when there is signal change in some ligaments only without abnormalities in Power's ratio, BDI, BAI-BDI and X-line, conservative management with stabilization may be the appropriate first-line treatment
  • Thoracic spinal fusion for scoliosis confirmed by imaging with Cobb angle greater than 40 degrees in skeletally immature children/adolescents, OR Cobb angle greater than 50 degrees associated with functional impairment in skeletally mature adults, that has failed 3 months of conservative management
  • Thoracic spinal fusion for thoracic kyphosis resulting in spinal cord compression, OR kyphotic curve greater than 75 degrees refractory to bracing, that has failed 3 months of conservative management
  • Thoracic spinal fusion for thoracic pseudarthrosis (absence of bridging bone connecting the vertebrae, or movement of vertebrae at the site of prior attempted arthrodesis on dynamic radiographs) after 12 months have elapsed OR with hardware failure. NOTE: nicotine-free 6 weeks required for non-urgent cases, with lab documentation required
  • Thoracic spinal fusion for burst fractures, fracture-dislocation with mechanical instability, locked facets, or unstable fractures confirmed by imaging
  • Thoracic spinal fusion for spinal infection confirmed by imaging/biopsy
  • Thoracic spinal fusion for spinal tumor (primary or metastatic) confirmed by imaging
  • Thoracic spinal fusion for spondylolisthesis with segmental instability confirmed by imaging (CT or MRI) when BOTH: significant spondylolisthesis grades II, III, IV, or V; AND symptomatic unremitting pain that has failed 6 weeks of conservative management (WAIVED for waiver indications)
  • Thoracic spinal fusion for spinal stenosis meeting thoracic decompression criteria AND ANY of: decompression in an area of segmental instability on flexion/extension radiographs; OR decompression coincides with any degree of anterolisthesis (grades I-V); OR decompression creates iatrogenic instability by disruption of the posterior elements (facet excision greater than 50% bilaterally or complete facet excision)
  • Lumbar spinal fusion for adult scoliosis confirmed by imaging with Cobb angle greater than 50 degrees associated with functional impairment in skeletally mature adults, that has failed 3 months of conservative management
  • Lumbar spinal fusion for lumbar pseudarthrosis (absence of bridging bone connecting the vertebrae, or movement of vertebrae at the site of prior attempted arthrodesis on dynamic radiographs) after 12 months have elapsed OR with hardware failure. NOTE: nicotine-free 6 weeks required, with lab documentation (nicotine level <=10 ng/ml) required
  • Lumbar spinal fusion for iatrogenic or degenerative flatback syndrome (back pain, stooped posture, and limitation of forward gaze) with significant sagittal imbalance that has failed 3 months of conservative management, when fusion is performed with spinal osteotomy and/or lordotic anterior interbody implants. Significant sagittal imbalance exists when ANY: offset >5 cm between the sagittal vertebral axis and posterior superior S1; OR pelvic tilt >20 degrees; OR lumbar lordosis to pelvic incidence mismatch >=10 degrees
  • Lumbar spinal fusion for spinal fracture causing instability or neural element compromise/compression, spinal dislocation (with mechanical instability), locked facets, or fracture with displaced fracture fragment confirmed by imaging. EXCLUDED: pars defects/fractures, subacute/chronic compression fractures, compression fractures without retropulsion causing significant stenosis, chronic stable odontoid fractures, spinous process fractures, transverse process fractures, and stable isolated pedicle fractures
  • Lumbar spinal fusion for pars defects (fractures) without significant instability (for spondylolisthesis use the spondylolisthesis criterion) with disc degeneration at the surgical level in members under 18 years who have failed >=6 months conservative management including bracing AND >=6 weeks formal in-person physical therapy within the past year
  • Lumbar spinal fusion for spinal infection confirmed by imaging/biopsy
  • Lumbar spinal fusion for spinal tumor confirmed by imaging
  • Lumbar spinal fusion for spondylolisthesis with segmental instability confirmed by imaging (CT or MRI) with associated symptomatic unremitting low back pain, radiculopathy, or neurogenic claudication, when EITHER: radiographic documentation of significant spondylolisthesis grades II, III, IV, or V with failure of 6 weeks conservative management (WAIVED for waiver indications); OR radiographic documentation of dynamic instability of at least 4 mm translation or 10 degrees of angular motion on dynamic imaging with failure of 6 weeks conservative management (WAIVED for waiver indications)
  • Lumbar spinal fusion for spinal stenosis meeting lumbar decompression criteria AND ANY of: decompression in an area of segmental instability on flexion/extension radiographs; OR decompression coincides with any degree of anterolisthesis (grades I-V); OR intraoperative iatrogenic instability from the initial primary laminectomy/discectomy; OR revision decompression creating iatrogenic instability by anterior/posterior disruption (facet excision greater than 50% bilaterally or complete facet excision)
  • Spinal surgery in patients with prior spinal surgery when the applicable laminectomy/decompression/corpectomy medical-necessity criteria are met
  • Removal of large anterior cervical osteophytes that are causing dysphagia (with or without anterior fusion), where the osteophytes are deemed the cause by an ENT specialist or certified speech therapist
  • Cervical laminoplasty (laminaplasty) for members with at least moderate cervical spinal stenosis at multiple (>=2) levels where 2 or more vertebral segments are to be decompressed, when ALL: other reasonable sources of pain/neurologic deficit ruled out; AND signs/symptoms of spinal cord compression (myelopathy) at the treated levels; AND imaging shows central stenosis (moderate or greater) or spinal cord compression at corresponding levels; AND imaging shows <=3 mm of motion on cervical flexion/extension x-rays and no cervical kyphosis; AND failed >=6 weeks conservative therapy (WAIVED for waiver indications)
  • Exploration of spinal fusion (CPT 22830) separately reimbursable when criteria for fusion for pseudarthrosis are met but intra-operative findings reveal solid fusion with no additional procedures. NOTE: incidental when performed in the same anatomic region as other procedures; cannot combine with other spinal procedures in the same area
  • Removal of posterior spinal instrumentation when ANY of: neurologic complication related to its ongoing presence (e.g., screw compressing a nerve root causing radiculopathy); OR new pain or protruding mass at the operative site after significant trauma; OR severe back/neck pain after the fusion has healed related to the instrumentation, with failed conservative management including >=6 weeks formal in-person physical therapy in the past year; OR spinal infection; OR symptomatic rod, hook, or screw migration, dislodgment, or breakage; OR vascular complications from the instrumentation; OR further approved surgery requiring removal. NOTE: removal necessary for an approved fusion is not reimbursable when new instrumentation is inserted at the previously instrumented levels
  • Removal of anterior spinal instrumentation when ANY of: further approved surgery requiring removal; OR neurologic or vascular complication from its ongoing presence; OR instrumentation failure/migration risking neurologic/vascular complications; OR spinal infection; OR dysphagia from esophageal compression by anterior cervical implants (confirmed by ENT/barium swallow). NOTE: removal for an approved fusion is not reimbursable with new instrumentation at the previously instrumented levels
  • Thoracolumbar osteotomy only when there is a significant deformity that meets criteria described elsewhere in this CPB. NOTE: laminectomies and TLIFs cannot be approved separately when combined with osteotomies
  • Excision of a portion of the bony spine (portion of the vertebral body, facets, or lamina) for a bony lesion when ALL: a bony lesion is documented on a formal advanced imaging report (CT or MRI); AND additional radiographic investigation completed to define the lesion if appropriate (angiogram, SPECT, PET); AND bone biopsy performed and pathology available; AND pathology documents a lesion for which medical literature supports excision and other treatments were considered; AND removal of the entire bone at that level is not indicated
  • Pelvic fixation where criteria for lumbar fusion are met, for ANY of: fusion from L2 or above to the sacrum; OR multi-level fusion with non-union or sacral insufficiency fracture; OR fusion of high-grade lumbosacral spondylolisthesis at L5/S1 (Grade 3 or higher)
  • Computer-assisted surgical navigation (stereotaxic navigation) approvable if fusion implants are being placed during surgery on the spinal column, with documented stereotaxic system identification, registration, imaging verification, and intraoperative use (NOT approvable during routine decompression, with possible exceptions for tumor decompressions)
  • Conservative management (footnote requirement): conservative measures must be recent (within the past year) and include patient education, active in-person physical therapy (not home/virtual), medications (NSAIDs, acetaminophen, tricyclic antidepressants), and identification/management of associated anxiety or depression; member must participate the full duration (6 weeks or 3 months depending on indication); confirmed by PT notes or member claims history
  • Waiver of the conservative-management requirement applies when ANY of: spinal cord compression (excludes nerve root compression); OR stenosis causing cauda equina syndrome; OR stenosis causing myelopathy (cervical/thoracic only, not lumbar); OR stenosis causing severe weakness of muscle(s) innervated at the requested surgical level(s) graded 4-minus or less on the MRC scale (4-minus strength describes muscle activation that is beyond antigravity (3/5) and produces motion against only slight resistance and fails against moderate resistance); OR progressive neurological deficit on serial examinations by the same surgeon; OR severe stenosis with instability (dynamic excursion on flexion/extension or supine-to-standing) when fusion is requested; OR a physical therapist discharge note documenting lack of utility of further therapy due to the member's inability to adapt to a tolerable treatment plan from exceptional pain
  • Spinal fusion prerequisite: member should be nicotine-free (including smoking, tobacco products, and nicotine replacement therapy) for at least 6 weeks prior to surgery; for recent (within a year) nicotine use, documentation of cessation should include a lab report (not surgeon summary) showing blood and/or urine nicotine <=10 ng/ml (or urinary cotinine <=10 ng/ml) drawn within 6 weeks prior to surgery -- UNLESS there is an indication (e.g., myelopathy, cauda equina syndrome), severe weakness (4-minus or less on MRC scale) or progressive weakness, or an associated infection/tumor and/or fracture
  • Spinal fusion prerequisite: if the member is diabetic, hemoglobin A1C (HbA1c) should be less than 8 percent within 3 months prior to surgery, unless there is an urgent indication for surgery (e.g., myelopathy, cauda equina syndrome), severe weakness (4-minus or less on MRC scale) or progressive weakness, or an associated infection/tumor and/or acute fracture
  • Elective laminectomy prerequisite: if the member is diabetic, HbA1c should be less than 8 percent within 3 months prior to surgery, unless there is an indication (e.g., myelopathy, cauda equina syndrome), severe weakness (4-minus or less on MRC scale) or progressive weakness, or an associated infection/tumor and/or acute fracture
  • Stenosis grading definitions (for purposes of this policy): CENTRAL stenosis grades -- normal or mild stenosis (ligamentum flavum hypertrophy and/or osteophytes and/or disk bulging without significant narrowing of the central spinal canal); moderate stenosis (central spinal canal narrowed such that there is minimal spinal fluid visible in the dural sac); severe stenosis (central spinal canal narrowed with only a faint amount of spinal fluid or no fluid in the dural sac; cord morphological change is a sign of severe stenosis). FORAMINAL stenosis grades -- mild (some perineural fat remains visible around the nerve root); moderate (minimal perineural fat but no morphological changes); severe (nerve root morphological change, not just nerve root displacement). Any nerve root or spinal cord compression meets criteria regardless of the degree of stenosis on the imaging report; terms such as mass effect, impingement, abutment, effacement, indentation, flattening or displacement do not substitute for compression.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • Medical records must document that a physical examination, including a neurologic examination, has been performed by or reviewed by the operating surgeon
  • Advanced imaging studies (CT, MRI, myelogram) are required prior to any spinal surgery; imaging must be performed within the past year, or after the onset of the current constellation of symptoms or any relevant surgical procedures, whichever is sooner
  • The official written report of advanced imaging studies is used; if the operating surgeon disagrees with the official written report, the surgeon must document the disagreement, discuss it with the interpreter, and obtain a written addendum to the official report indicating agreement or disagreement
  • Conservative management / physical therapy participation must be documented by physical therapy notes or member claims history
  • For pseudarthrosis cases without hardware failure or urgent need (and for recent nicotine users prior to fusion): a lab report (not a surgeon summary) showing blood/urine nicotine <=10 ng/ml (or urinary cotinine <=10 ng/ml) drawn within 6 weeks prior to surgery
  • For diabetic members: HbA1c lab result (less than 8 percent within 3 months prior to surgery) for elective laminectomy/fusion unless an urgent/qualifying indication applies
  • For waiver of conservative management based on exceptional pain: a physical therapist discharge note documenting lack of utility of further therapy due to the member's inability to adapt to a tolerable treatment plan
  • For anterior cervical osteophyte removal causing dysphagia: documentation that an ENT specialist or certified speech therapist deemed the osteophytes the cause (for anterior instrumentation removal due to dysphagia, ENT confirmation and/or barium swallow)
  • For excision of a bony spine lesion: formal advanced imaging report (CT/MRI) documenting the lesion, appropriate additional radiographic investigation (angiogram/SPECT/PET) if indicated, and a bone biopsy with available pathology
  • For computer-assisted surgical navigation: documentation identifying the stereotaxic system, registration, imaging verification, and its intraoperative use

Frequently asked questions

When does Aetna cover Spinal Surgery: Laminectomy and Fusion (CPT 22548), and what gets it denied?
Aetna CPB 0743 covers spinal laminectomy/decompression, corpectomy, and cervical/thoracic/lumbar spinal fusion (plus laminoplasty, instrumentation removal, osteotomy, and pelvic fixation) only when documented imaging shows moderate-or-worse stenosis or true nerve/cord compression (or a specific structural condition such as fracture, tumor, infection, deformity, instability, or spondylolisthesis), the member has neural-compression symptoms limiting daily activities, and the member has failed the required course of conservative therapy (6 weeks or 3 months) unless an urgent indication such as myelopathy, cauda equina, severe/progressive weakness, or tumor/infection/fracture waives that wait; fusion additionally requires lab-documented nicotine cessation and HbA1c below 8% in diabetics unless urgent. Decompression/fusion for degenerative disc disease, mechanical axial pain without myelopathy, Bertolotti's syndrome, internal jugular vein stenosis, and indications not specifically listed are experimental/investigational or not covered. Coverage criteria include: Cervical laminectomy and/or anterior or posterior cervical discectomy and fusion for herniated discs or other causes of spinal cord or nerve root compression (osteophytic spurring, ligamentous hypertrophy) when ALL of the following: (1) all other reasonable sources of pain and/or neurological deficit have been ruled out, including but not limited to significant pathology at other spinal level(s) on the advanced imaging radiology report that is/are not part of the surgical request resulting in incomplete surgical planning; AND (2) member has signs/symptoms of neural compression (radiculopathy, neurogenic claudication, or myelopathy) at the treated levels; AND (3) advanced imaging (CT or MRI) indicates central, lateral recess, or foraminal stenosis graded moderate, moderate-to-severe, or severe (NOT mild or mild-to-moderate), or nerve root or spinal cord compression, at the level corresponding with the clinical findings; AND (4) member has failed at least 6 weeks of conservative therapy (WAIVED for the listed waiver indications); AND (5) member's activities of daily living are limited by symptoms of neural compression; Thoracic laminectomy and/or thoracic discectomy and fusion for herniated discs or other causes of thoracic nerve root compression (osteophytic spurring, ligamentous hypertrophy) when ALL of the following: (1) all other reasonable sources of pain/neurological deficit ruled out, including but not limited to significant pathology at other spinal level(s) on the advanced imaging radiology report that is/are not part of the surgical request resulting in incomplete surgical planning; AND (2) signs/symptoms of neural compression (radiculopathy, neurogenic claudication, myelopathy) at treated levels; AND (3) advanced imaging (CT/MRI) shows central/lateral recess/foraminal stenosis graded moderate, moderate-to-severe, or severe (not mild/mild-to-moderate), or nerve root or spinal cord compression, at the level corresponding with the clinical findings; AND (4) failed at least 6 weeks conservative therapy (WAIVED for waiver indications); AND (5) ADLs limited by symptoms of neural compression; Lumbar laminectomy for herniated disc when ALL of the following: (1) all other reasonable sources of pain/neurological deficit ruled out, including but not limited to significant pathology at other spinal level(s) on the advanced imaging radiology report that is/are not part of the surgical request resulting in incomplete surgical planning; AND (2) signs/symptoms of neural compression (radiculopathy, neurogenic extremity claudication, myelopathy) at treated levels; AND (3) advanced imaging (CT/MRI) shows central/lateral recess/foraminal stenosis graded moderate, moderate-to-severe, or severe (not mild/mild-to-moderate), or nerve root or spinal cord compression, at the level corresponding with the clinical findings; AND (4) failed at least 6 weeks conservative therapy (WAIVED for waiver indications); AND (5) ADLs limited by symptoms of neural compression; Cervical, thoracic, lumbar, or sacral laminectomy for ANY ONE of the following: spinal fracture with displaced fragments causing moderate-or-greater stenosis/nerve compression (imaging confirmed) with signs/symptoms of nerve compression; OR spinal infection confirmed by imaging; OR spinal tumor confirmed by imaging; OR epidural hematomas confirmed by imaging; OR synovial cysts, Tarlov cysts (perineurial/sacral meningeal cysts), or arachnoid cysts causing spinal cord or nerve root compression with unremitting pain after failed 6 weeks conservative therapy (WAIVED for waiver indications); OR spinal stenosis (central, lateral recess, or foraminal) graded moderate, moderate-to-severe, or severe (not mild/mild-to-moderate) with unremitting pain, confirmed by imaging at the level corresponding to neurological findings, after failed 6 weeks conservative therapy (WAIVED for waiver indications); OR repair of open spinal dysraphism, or radiographically demonstrated closed spinal dysraphism (including tethered cord) with significant signs/symptoms of lumbosacral dysfunction, or radiographically demonstrated closed spinal dysraphism in asymptomatic young children not yet toilet trained or not yet walking; OR other mass lesions confirmed by imaging upon individual case review; Lumbar decompression with or without discectomy for rapid progression of neurological impairment (foot drop, extremity weakness, saddle anesthesia, bladder/bowel dysfunction) with central, lateral recess, or foraminal stenosis (moderate or worse) confirmed by imaging at the levels corresponding to the neurologic findings; Vertebral corpectomy (removal of half or more of the vertebral body) for ANY of: tumors involving one or more vertebrae; OR greater than 50% compression fracture; OR retro-pulsed bone fragments; OR symptomatic moderate-or-greater central canal stenosis arising from vertebral body pathology (fracture, tumor, or congenital/acquired deformity); Cervical spinal fusion for cervical kyphosis associated with cord compression; Cervical spinal fusion for symptomatic pseudarthrosis (non-union of prior fusion) with radiological demonstration of non-union after 12 months have elapsed OR with hardware failure. NOTE: for pseudarthrosis without hardware failure or urgent need, member must be nicotine-free for 6 weeks prior, with lab documentation (nicotine level <=10 ng/ml) required; Cervical spinal fusion for burst fractures, fracture-dislocation with mechanical instability, locked facets, or unstable fractures confirmed by imaging; Cervical spinal fusion for spinal infection confirmed by imaging/biopsy; Cervical spinal fusion for spinal tumor (primary or metastatic) confirmed by imaging; Cervical spinal fusion for atlantoaxial (C1-C2) subluxation (e.g., associated with congenital anomaly, os odontoideum, or rheumatoid arthritis) noted as widening of the atlantodens interval greater than 3 mm; Cervical spinal fusion for basilar invagination of the odontoid process into the foramen magnum; Cervical spinal fusion for sub-axial (C2-T1) instability confirmed by imaging when BOTH: significant instability (sagittal plane translation of at least 3 mm on flexion/extension views OR relative sagittal plane angulation greater than 11 degrees); AND symptomatic unremitting pain that has failed 3 months of conservative management (WAIVED for waiver indications); Cervical spinal fusion as adjunct to excision of synovial cysts causing cord/nerve compression with unremitting pain after failed 6 weeks conservative therapy (WAIVED for waiver indications or progressive deficit); Cervical spinal fusion for clinically significant deformity of the spine (kyphosis, head-drop syndrome, post-laminectomy deformity) after failed 6 weeks conservative therapy and nicotine-free 6 weeks, when ANY of: deformity prohibits forward gaze; OR associated with severe neck pain, difficulty ambulating, AND interference with ADL; OR documented progression of deformity; Cervical spinal fusion for occipito-cervical instability (seen in Down's syndrome, the mucopolysaccharidoses, and rheumatoid arthritis; occipito-cervical dislocation/instability also seen after high-energy trauma). A Power's ratio greater than 1.0 raises concern for occipito-cervical dislocation, and a basion-dens (BD) or basion-posterior axial interval (BAI) greater than 12 mm suggests occipito-cervical dissociation/instability (BD plus BAI is the Harris method, best measured on CT). Medically necessary in traumatic cases with documented instability via Harris measurements and ligamentous disruption; also for congenital/acquired cases (e.g., Down's syndrome, mucopolysaccharidoses, rheumatoid arthritis) with cord compression at the occipito-cervical junction. NOTE: when there is signal change in some ligaments only without abnormalities in Power's ratio, BDI, BAI-BDI and X-line, conservative management with stabilization may be the appropriate first-line treatment; Thoracic spinal fusion for scoliosis confirmed by imaging with Cobb angle greater than 40 degrees in skeletally immature children/adolescents, OR Cobb angle greater than 50 degrees associated with functional impairment in skeletally mature adults, that has failed 3 months of conservative management; Thoracic spinal fusion for thoracic kyphosis resulting in spinal cord compression, OR kyphotic curve greater than 75 degrees refractory to bracing, that has failed 3 months of conservative management; Thoracic spinal fusion for thoracic pseudarthrosis (absence of bridging bone connecting the vertebrae, or movement of vertebrae at the site of prior attempted arthrodesis on dynamic radiographs) after 12 months have elapsed OR with hardware failure. NOTE: nicotine-free 6 weeks required for non-urgent cases, with lab documentation required; Thoracic spinal fusion for burst fractures, fracture-dislocation with mechanical instability, locked facets, or unstable fractures confirmed by imaging; Thoracic spinal fusion for spinal infection confirmed by imaging/biopsy; Thoracic spinal fusion for spinal tumor (primary or metastatic) confirmed by imaging; Thoracic spinal fusion for spondylolisthesis with segmental instability confirmed by imaging (CT or MRI) when BOTH: significant spondylolisthesis grades II, III, IV, or V; AND symptomatic unremitting pain that has failed 6 weeks of conservative management (WAIVED for waiver indications); Thoracic spinal fusion for spinal stenosis meeting thoracic decompression criteria AND ANY of: decompression in an area of segmental instability on flexion/extension radiographs; OR decompression coincides with any degree of anterolisthesis (grades I-V); OR decompression creates iatrogenic instability by disruption of the posterior elements (facet excision greater than 50% bilaterally or complete facet excision); Lumbar spinal fusion for adult scoliosis confirmed by imaging with Cobb angle greater than 50 degrees associated with functional impairment in skeletally mature adults, that has failed 3 months of conservative management; Lumbar spinal fusion for lumbar pseudarthrosis (absence of bridging bone connecting the vertebrae, or movement of vertebrae at the site of prior attempted arthrodesis on dynamic radiographs) after 12 months have elapsed OR with hardware failure. NOTE: nicotine-free 6 weeks required, with lab documentation (nicotine level <=10 ng/ml) required; Lumbar spinal fusion for iatrogenic or degenerative flatback syndrome (back pain, stooped posture, and limitation of forward gaze) with significant sagittal imbalance that has failed 3 months of conservative management, when fusion is performed with spinal osteotomy and/or lordotic anterior interbody implants. Significant sagittal imbalance exists when ANY: offset >5 cm between the sagittal vertebral axis and posterior superior S1; OR pelvic tilt >20 degrees; OR lumbar lordosis to pelvic incidence mismatch >=10 degrees; Lumbar spinal fusion for spinal fracture causing instability or neural element compromise/compression, spinal dislocation (with mechanical instability), locked facets, or fracture with displaced fracture fragment confirmed by imaging. EXCLUDED: pars defects/fractures, subacute/chronic compression fractures, compression fractures without retropulsion causing significant stenosis, chronic stable odontoid fractures, spinous process fractures, transverse process fractures, and stable isolated pedicle fractures; Lumbar spinal fusion for pars defects (fractures) without significant instability (for spondylolisthesis use the spondylolisthesis criterion) with disc degeneration at the surgical level in members under 18 years who have failed >=6 months conservative management including bracing AND >=6 weeks formal in-person physical therapy within the past year; Lumbar spinal fusion for spinal infection confirmed by imaging/biopsy; Lumbar spinal fusion for spinal tumor confirmed by imaging; Lumbar spinal fusion for spondylolisthesis with segmental instability confirmed by imaging (CT or MRI) with associated symptomatic unremitting low back pain, radiculopathy, or neurogenic claudication, when EITHER: radiographic documentation of significant spondylolisthesis grades II, III, IV, or V with failure of 6 weeks conservative management (WAIVED for waiver indications); OR radiographic documentation of dynamic instability of at least 4 mm translation or 10 degrees of angular motion on dynamic imaging with failure of 6 weeks conservative management (WAIVED for waiver indications); Lumbar spinal fusion for spinal stenosis meeting lumbar decompression criteria AND ANY of: decompression in an area of segmental instability on flexion/extension radiographs; OR decompression coincides with any degree of anterolisthesis (grades I-V); OR intraoperative iatrogenic instability from the initial primary laminectomy/discectomy; OR revision decompression creating iatrogenic instability by anterior/posterior disruption (facet excision greater than 50% bilaterally or complete facet excision); Spinal surgery in patients with prior spinal surgery when the applicable laminectomy/decompression/corpectomy medical-necessity criteria are met; Removal of large anterior cervical osteophytes that are causing dysphagia (with or without anterior fusion), where the osteophytes are deemed the cause by an ENT specialist or certified speech therapist; Cervical laminoplasty (laminaplasty) for members with at least moderate cervical spinal stenosis at multiple (>=2) levels where 2 or more vertebral segments are to be decompressed, when ALL: other reasonable sources of pain/neurologic deficit ruled out; AND signs/symptoms of spinal cord compression (myelopathy) at the treated levels; AND imaging shows central stenosis (moderate or greater) or spinal cord compression at corresponding levels; AND imaging shows <=3 mm of motion on cervical flexion/extension x-rays and no cervical kyphosis; AND failed >=6 weeks conservative therapy (WAIVED for waiver indications); Exploration of spinal fusion (CPT 22830) separately reimbursable when criteria for fusion for pseudarthrosis are met but intra-operative findings reveal solid fusion with no additional procedures. NOTE: incidental when performed in the same anatomic region as other procedures; cannot combine with other spinal procedures in the same area; Removal of posterior spinal instrumentation when ANY of: neurologic complication related to its ongoing presence (e.g., screw compressing a nerve root causing radiculopathy); OR new pain or protruding mass at the operative site after significant trauma; OR severe back/neck pain after the fusion has healed related to the instrumentation, with failed conservative management including >=6 weeks formal in-person physical therapy in the past year; OR spinal infection; OR symptomatic rod, hook, or screw migration, dislodgment, or breakage; OR vascular complications from the instrumentation; OR further approved surgery requiring removal. NOTE: removal necessary for an approved fusion is not reimbursable when new instrumentation is inserted at the previously instrumented levels; Removal of anterior spinal instrumentation when ANY of: further approved surgery requiring removal; OR neurologic or vascular complication from its ongoing presence; OR instrumentation failure/migration risking neurologic/vascular complications; OR spinal infection; OR dysphagia from esophageal compression by anterior cervical implants (confirmed by ENT/barium swallow). NOTE: removal for an approved fusion is not reimbursable with new instrumentation at the previously instrumented levels; Thoracolumbar osteotomy only when there is a significant deformity that meets criteria described elsewhere in this CPB. NOTE: laminectomies and TLIFs cannot be approved separately when combined with osteotomies; Excision of a portion of the bony spine (portion of the vertebral body, facets, or lamina) for a bony lesion when ALL: a bony lesion is documented on a formal advanced imaging report (CT or MRI); AND additional radiographic investigation completed to define the lesion if appropriate (angiogram, SPECT, PET); AND bone biopsy performed and pathology available; AND pathology documents a lesion for which medical literature supports excision and other treatments were considered; AND removal of the entire bone at that level is not indicated; Pelvic fixation where criteria for lumbar fusion are met, for ANY of: fusion from L2 or above to the sacrum; OR multi-level fusion with non-union or sacral insufficiency fracture; OR fusion of high-grade lumbosacral spondylolisthesis at L5/S1 (Grade 3 or higher); Computer-assisted surgical navigation (stereotaxic navigation) approvable if fusion implants are being placed during surgery on the spinal column, with documented stereotaxic system identification, registration, imaging verification, and intraoperative use (NOT approvable during routine decompression, with possible exceptions for tumor decompressions); Conservative management (footnote requirement): conservative measures must be recent (within the past year) and include patient education, active in-person physical therapy (not home/virtual), medications (NSAIDs, acetaminophen, tricyclic antidepressants), and identification/management of associated anxiety or depression; member must participate the full duration (6 weeks or 3 months depending on indication); confirmed by PT notes or member claims history; Waiver of the conservative-management requirement applies when ANY of: spinal cord compression (excludes nerve root compression); OR stenosis causing cauda equina syndrome; OR stenosis causing myelopathy (cervical/thoracic only, not lumbar); OR stenosis causing severe weakness of muscle(s) innervated at the requested surgical level(s) graded 4-minus or less on the MRC scale (4-minus strength describes muscle activation that is beyond antigravity (3/5) and produces motion against only slight resistance and fails against moderate resistance); OR progressive neurological deficit on serial examinations by the same surgeon; OR severe stenosis with instability (dynamic excursion on flexion/extension or supine-to-standing) when fusion is requested; OR a physical therapist discharge note documenting lack of utility of further therapy due to the member's inability to adapt to a tolerable treatment plan from exceptional pain; Spinal fusion prerequisite: member should be nicotine-free (including smoking, tobacco products, and nicotine replacement therapy) for at least 6 weeks prior to surgery; for recent (within a year) nicotine use, documentation of cessation should include a lab report (not surgeon summary) showing blood and/or urine nicotine <=10 ng/ml (or urinary cotinine <=10 ng/ml) drawn within 6 weeks prior to surgery -- UNLESS there is an indication (e.g., myelopathy, cauda equina syndrome), severe weakness (4-minus or less on MRC scale) or progressive weakness, or an associated infection/tumor and/or fracture; Spinal fusion prerequisite: if the member is diabetic, hemoglobin A1C (HbA1c) should be less than 8 percent within 3 months prior to surgery, unless there is an urgent indication for surgery (e.g., myelopathy, cauda equina syndrome), severe weakness (4-minus or less on MRC scale) or progressive weakness, or an associated infection/tumor and/or acute fracture; Elective laminectomy prerequisite: if the member is diabetic, HbA1c should be less than 8 percent within 3 months prior to surgery, unless there is an indication (e.g., myelopathy, cauda equina syndrome), severe weakness (4-minus or less on MRC scale) or progressive weakness, or an associated infection/tumor and/or acute fracture; Stenosis grading definitions (for purposes of this policy): CENTRAL stenosis grades -- normal or mild stenosis (ligamentum flavum hypertrophy and/or osteophytes and/or disk bulging without significant narrowing of the central spinal canal); moderate stenosis (central spinal canal narrowed such that there is minimal spinal fluid visible in the dural sac); severe stenosis (central spinal canal narrowed with only a faint amount of spinal fluid or no fluid in the dural sac; cord morphological change is a sign of severe stenosis). FORAMINAL stenosis grades -- mild (some perineural fat remains visible around the nerve root); moderate (minimal perineural fat but no morphological changes); severe (nerve root morphological change, not just nerve root displacement). Any nerve root or spinal cord compression meets criteria regardless of the degree of stenosis on the imaging report; terms such as mass effect, impingement, abutment, effacement, indentation, flattening or displacement do not substitute for compression.. Applies to 44 codes: 22548, 22551, 22552, 22554, 22590, 22595, 22600, 22612, 22614, 22630, 22632, 22633, 22634, 63001, 63003, 63005, 63012, 63015, 63016, 63017, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63055, 63056, 63057, 63075, 63076, 63077, 63078, 22840, 22842, 22845, 22853, 22854. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Medical records must document that a physical examination, including a neurologic examination, has been performed by or reviewed by the operating surgeon; Advanced imaging studies (CT, MRI, myelogram) are required prior to any spinal surgery; imaging must be performed within the past year, or after the onset of the current constellation of symptoms or any relevant surgical procedures, whichever is sooner; The official written report of advanced imaging studies is used; if the operating surgeon disagrees with the official written report, the surgeon must document the disagreement, discuss it with the interpreter, and obtain a written addendum to the official report indicating agreement or disagreement; Conservative management / physical therapy participation must be documented by physical therapy notes or member claims history; For pseudarthrosis cases without hardware failure or urgent need (and for recent nicotine users prior to fusion): a lab report (not a surgeon summary) showing blood/urine nicotine <=10 ng/ml (or urinary cotinine <=10 ng/ml) drawn within 6 weeks prior to surgery; For diabetic members: HbA1c lab result (less than 8 percent within 3 months prior to surgery) for elective laminectomy/fusion unless an urgent/qualifying indication applies; For waiver of conservative management based on exceptional pain: a physical therapist discharge note documenting lack of utility of further therapy due to the member's inability to adapt to a tolerable treatment plan; For anterior cervical osteophyte removal causing dysphagia: documentation that an ENT specialist or certified speech therapist deemed the osteophytes the cause (for anterior instrumentation removal due to dysphagia, ENT confirmation and/or barium swallow); For excision of a bony spine lesion: formal advanced imaging report (CT/MRI) documenting the lesion, appropriate additional radiographic investigation (angiogram/SPECT/PET) if indicated, and a bone biopsy with available pathology; For computer-assisted surgical navigation: documentation identifying the stereotaxic system, registration, imaging verification, and its intraoperative use. Policy exclusions and limitations: Experimental, investigational, or unproven (for all indications not listed as medically necessary): avulsion of spinal nerves; Experimental, investigational, or unproven: cervical, thoracic, and lumbar laminectomy and/or fusion for indications not listed as medically necessary; Experimental, investigational, or unproven: cervical laminoplasty for treatment of cervical kyphosis, for mechanical axial neck pain (cervical strain) without myelopathy, and for all other indications not listed as medically necessary; Experimental, investigational, or unproven: inter-laminar lumbar instrumented fusion (ILIF) and the Coflex-F implant for lumbar fusion (see CPB 0016); see also CPB 0772 - Axial Lumbar Interbody Fusion (AxiaLIF); Experimental, investigational, or unproven: computer-assisted surgical navigation for laminectomies. NOTE: robotic assistance is considered integral to the primary procedure and not separately reimbursed; Experimental, investigational, or unproven: lumbar spinal fusion for degenerative disc disease and all other indications not listed as medically necessary; Experimental, investigational, or unproven: occipito-cervical fusion/stabilization not listed as medically necessary; Experimental, investigational, or unproven: removal of the C1 tubercle or transverse process, or cervical laminectomy, for treatment of internal jugular vein stenosis; Experimental, investigational, or unproven: surgery for Bertolotti's syndrome (fusion or resection of the lumbosacral articulation); Not medically necessary: paraspinal muscle flap closure or tissue transfer (by a plastic or other surgeon, including the operating surgeon) at the time of spinal surgeries, as wound closure is included in the surgery and not separately reimbursable, and there is no literature evidence that particular methods of wound closure produce improved outcomes; Not covered: cervical laminoplasty for cervical kyphosis; Not covered: cervical laminoplasty for other/unspecified cervical disc disorders; Not covered: cervical laminoplasty for cervical spondylosis with myelopathy; Not covered: cervical laminoplasty for cervical spondylosis without myelopathy; Not covered: cervical laminoplasty for cervical disc disorder with radiculopathy; Not covered: cervical laminoplasty for other cervical disc displacement; Not covered: cervical laminoplasty for other cervical disc degeneration; Not covered: cervical laminoplasty for cervicocranial syndrome; Not covered: cervical laminoplasty for cervicobrachial syndrome; Not covered: cervical laminoplasty for other specified dorsopathies; Not covered: cervical laminoplasty for cervicalgia; Not covered: cervical laminoplasty for occipital neuralgia; Not covered: cervical laminoplasty for other/unspecified dorsalgia; Not covered: cervical laminoplasty for contracture of muscle; Not covered: cervical laminoplasty for postlaminectomy syndrome; Not covered: cervical laminoplasty for subluxation complex (cervical); Not covered: cervical laminoplasty for congenital cervical kyphosis; Not covered: cervical laminoplasty for subluxation/dislocation of cervical vertebra; Not covered: cervical laminoplasty for sprain/strain of cervical spine ligaments; Not covered: cervical, thoracic, lumbar/sacral laminectomy for internal jugular vein stenosis; Not covered: lumbar spinal fusion for other thoracic/thoracolumbar/lumbosacral intervertebral disc degeneration; Not covered: lumbar spinal fusion for Bertolotti's syndrome; Excluded indications for lumbar fusion for spinal fracture: pars defects/fractures, subacute/chronic compression fractures, compression fractures without retropulsion causing significant stenosis, chronic stable odontoid fractures, spinous process fractures, transverse process fractures, and stable isolated pedicle fractures. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Spinal Surgery: Laminectomy and Fusion?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Medical records must document that a physical examination, including a neurologic examination, has been performed by or reviewed by the operating surgeon; Advanced imaging studies (CT, MRI, myelogram) are required prior to any spinal surgery; imaging must be performed within the past year, or after the onset of the current constellation of symptoms or any relevant surgical procedures, whichever is sooner; The official written report of advanced imaging studies is used; if the operating surgeon disagrees with the official written report, the surgeon must document the disagreement, discuss it with the interpreter, and obtain a written addendum to the official report indicating agreement or disagreement; Conservative management / physical therapy participation must be documented by physical therapy notes or member claims history; For pseudarthrosis cases without hardware failure or urgent need (and for recent nicotine users prior to fusion): a lab report (not a surgeon summary) showing blood/urine nicotine <=10 ng/ml (or urinary cotinine <=10 ng/ml) drawn within 6 weeks prior to surgery; For diabetic members: HbA1c lab result (less than 8 percent within 3 months prior to surgery) for elective laminectomy/fusion unless an urgent/qualifying indication applies; For waiver of conservative management based on exceptional pain: a physical therapist discharge note documenting lack of utility of further therapy due to the member's inability to adapt to a tolerable treatment plan; For anterior cervical osteophyte removal causing dysphagia: documentation that an ENT specialist or certified speech therapist deemed the osteophytes the cause (for anterior instrumentation removal due to dysphagia, ENT confirmation and/or barium swallow); For excision of a bony spine lesion: formal advanced imaging report (CT/MRI) documenting the lesion, appropriate additional radiographic investigation (angiogram/SPECT/PET) if indicated, and a bone biopsy with available pathology; For computer-assisted surgical navigation: documentation identifying the stereotaxic system, registration, imaging verification, and its intraoperative use.
What does Aetna exclude for Spinal Surgery: Laminectomy and Fusion?
Policy exclusions and limitations: Experimental, investigational, or unproven (for all indications not listed as medically necessary): avulsion of spinal nerves; Experimental, investigational, or unproven: cervical, thoracic, and lumbar laminectomy and/or fusion for indications not listed as medically necessary; Experimental, investigational, or unproven: cervical laminoplasty for treatment of cervical kyphosis, for mechanical axial neck pain (cervical strain) without myelopathy, and for all other indications not listed as medically necessary; Experimental, investigational, or unproven: inter-laminar lumbar instrumented fusion (ILIF) and the Coflex-F implant for lumbar fusion (see CPB 0016); see also CPB 0772 - Axial Lumbar Interbody Fusion (AxiaLIF); Experimental, investigational, or unproven: computer-assisted surgical navigation for laminectomies. NOTE: robotic assistance is considered integral to the primary procedure and not separately reimbursed; Experimental, investigational, or unproven: lumbar spinal fusion for degenerative disc disease and all other indications not listed as medically necessary; Experimental, investigational, or unproven: occipito-cervical fusion/stabilization not listed as medically necessary; Experimental, investigational, or unproven: removal of the C1 tubercle or transverse process, or cervical laminectomy, for treatment of internal jugular vein stenosis; Experimental, investigational, or unproven: surgery for Bertolotti's syndrome (fusion or resection of the lumbosacral articulation); Not medically necessary: paraspinal muscle flap closure or tissue transfer (by a plastic or other surgeon, including the operating surgeon) at the time of spinal surgeries, as wound closure is included in the surgery and not separately reimbursable, and there is no literature evidence that particular methods of wound closure produce improved outcomes; Not covered: cervical laminoplasty for cervical kyphosis; Not covered: cervical laminoplasty for other/unspecified cervical disc disorders; Not covered: cervical laminoplasty for cervical spondylosis with myelopathy; Not covered: cervical laminoplasty for cervical spondylosis without myelopathy; Not covered: cervical laminoplasty for cervical disc disorder with radiculopathy; Not covered: cervical laminoplasty for other cervical disc displacement; Not covered: cervical laminoplasty for other cervical disc degeneration; Not covered: cervical laminoplasty for cervicocranial syndrome; Not covered: cervical laminoplasty for cervicobrachial syndrome; Not covered: cervical laminoplasty for other specified dorsopathies; Not covered: cervical laminoplasty for cervicalgia; Not covered: cervical laminoplasty for occipital neuralgia; Not covered: cervical laminoplasty for other/unspecified dorsalgia; Not covered: cervical laminoplasty for contracture of muscle; Not covered: cervical laminoplasty for postlaminectomy syndrome; Not covered: cervical laminoplasty for subluxation complex (cervical); Not covered: cervical laminoplasty for congenital cervical kyphosis; Not covered: cervical laminoplasty for subluxation/dislocation of cervical vertebra; Not covered: cervical laminoplasty for sprain/strain of cervical spine ligaments; Not covered: cervical, thoracic, lumbar/sacral laminectomy for internal jugular vein stenosis; Not covered: lumbar spinal fusion for other thoracic/thoracolumbar/lumbosacral intervertebral disc degeneration; Not covered: lumbar spinal fusion for Bertolotti's syndrome; Excluded indications for lumbar fusion for spinal fracture: pars defects/fractures, subacute/chronic compression fractures, compression fractures without retropulsion causing significant stenosis, chronic stable odontoid fractures, spinous process fractures, transverse process fractures, and stable isolated pedicle fractures. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0743 — Spinal Surgery: Laminectomy and Fusion

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0743 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.