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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that spinal fusion should only be considered as a last step in the treatment of chronic back pain
and is not indicated for most persons suffering from back pain. Lumbar spinal fusion surgery may be
considered medically necessary and covered for the following indications: 1. Lumbar spinal instability for
ANY of the following indications when confirmed by appropriate diagnostic testing (e.g., radiographic
imaging, biopsy, bone aspirate, bone scan and gallium scan):Acute spinal fracture Progressive or significant
acute neurological impairment (e.g., increased weakness or bladder instability)Neural compression after spinal
fracture Epidural compression or vertebral destruction from tumor or abscess Spinal tuberculosis Spinal
debridement for infection (e.g., osteomyelitis)Spinal deformity (examples include but not limited to idiopathic
scoliosis over 40 degrees, progressive degenerative scoliosis [including spinal levels from the cranial to caudal
ends of the deformity and the adjacent normal segment], and sagittal plane deformity + sagittal balance over
10cm)2. Spinal stenosis for a single level (for example, L4-L5) with associated spondylolisthesis (see
classifications below in section 3) or other documented evidence of instability (for example, facet joint
instability [iatrogenic] related to decompression), AND symptoms of spinal claudication and radicular pain.
The pain must represent a significant functional impairment despite a history of 3 months of conservative
therapy (non-surgical medical management) as clinically appropriate addressing the following: Activity
lifestyle modification, Daily exercise, Supervised physical therapy (PT) (activities of daily living
(ADLs)diminished despite completing a plan of care)and Anti-inflammatory medications, oral or injection
therapy as appropriate, and analgesics. 3. Spondylolisthesis manifested by back pain WITH OR WITHOUT
spinal claudication, radicular pain, motor deficit when ANY of the following criteria are met: Confirmed
progressive deformity usually Grade II or higher or Multilevel spondylolysis. Symptomatic low-grade
spondylolisthesis associated with back pain and significant functional impairment despite a history of 3 months
of conservative therapy (non-surgical medical management) as clinically appropriate addressing the following:
activity lifestyle modification; daily exercise; supervised PT (ADLs diminished despite completing a plan of
care); and anti-inflammatory medications, oral or injection therapy as appropriate, and analgesics:
Classification of slippage in spondylolisthesis is defined as follows: Grade I =1% to 25%, Grade II =26% to
50%, Grade III =51% to 75%, Grade IV = 76% to 100%and Grade V = spondyloptosis and occurs when the L5
vertebra completely slides over the top of the sacrum. 4. Degenerative disc disease (DDD) in the absence of
instability when all of the following criteria have been met as clinically appropriate for the patient's current
episode of care: Single level DDD demonstrated on imaging studies (e.g., CT scan, MRI, or discography) as
the likely cause of pain. The case specific indications for two level or the rare three or more level planned
fusion procedure must be directly addressed in the pre procedure record with clinical correlation to diagnostic
testing results (such as disk-space narrowing, end plate changes, annular changes, etc.).Pain and significant
functional impairment despite a history of at least 6months of conservative therapy (non-surgical medical
management) as clinically appropriate addressing the following: Anti-inflammatory medications, oral or
injection therapy as appropriate, and analgesics, Daily exercise, Activity lifestyle modification, Weight
reduction as appropriate, Supervised PT [ADLs diminished despite completing a plan of care]OR Unsuccessful
improvement after completion of intense multidisciplinary rehabilitation (IMR). IMR is defined as onsite
program that includes supervised PT, cognitive behavior component, and other coordinated interventions by
health care professionals. Failure of non-surgical medical management can be historical and does not have to
be under the direction of the operating surgeon.5. Lumbar fusion following prior spinal surgery for the
following: Recurrent disc herniation despite clinically appropriate post-operative nonsurgical medical
management (post-operative case specific conservative therapy is prescribed as clinically appropriate in
addition to documentation of pain and functional impairment).Adjacent segment degeneration or disc
herniation despite clinically appropriate post-operative nonsurgical medical management (post-operative case
specific conservative therapy is prescribed as clinically appropriate in addition to documentation of pain and
functional impairment). Associated spondylolisthesis (for example anterolisthesis) after prior spinal surgery
with ALL the following as clinically appropriate: Recurrent symptoms consistent with neurological
compromise, Significant functional impairment, Neural compression is documented by recent post -operative
imaging, Unsuccessful improvement despite 3 months of clinically appropriate post-operative nonsurgical
medical management (post-operative case specific conservative therapy is prescribed as clinically appropriate
in addition to documentation of pain and functional impairment), Instability is documented by appropriate
imaging and Patient had some relief of pain symptoms following the prior spinal surgery. 6. Treatment of
pseudoarthrosis (i.e., nonunion of prior fusion) at the same level after 12 months from prior surgery and ALL
of the following are met (unless imaging demonstrates failed spinal instrumentation [for example, fractured rod
or loosened screw]):Imaging studies confirm evidence of pseudoarthrosis (e.g., radiographs, CT), Unsuccessful
improvement despite 3 months of clinically appropriate post-operative nonsurgical medical management (postoperative
case specific conservative therapy is prescribed as clinically appropriate in addition to documentation
of pain and functional impairment), Patient had some relief of pain symptoms following the prior spinal
surgery. You can find this rule in the Local Coverage Determination (LCD): Lumbar Spinal Fusion for
Instability and Degenerative Disc Conditions (L33382) effective January 8, 2019.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.