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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 state that the following are indications of spinal fusion: 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)
-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
-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%
-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 6 months 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
-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 (post-operative 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 these rules in the Local Coverage Determination (LCD) for Lumbar Spinal Fusion for Instability and Degenerative Disc Conditions, L33382. This LCD is effective for services provided on or after 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.