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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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules state that lumbar fusion must be performed by a qualified surgeon in an operating room with the 
necessary equipment. For elective surgeries, providers should verify that the necessary equipment and 
hardware to perform the procedure on a patient is available prior to the induction of anesthesia. Documentation 
must demonstrate that the patient met at least 1 of the indications for the procedure as described below. Where 
possible, there must be documented shared decision making with the patient or the individual who is serving as 
the proxy decision maker for the patient with the appropriate discussion of anticipated risks and benefits of the 
procedure. 
 
Indications for lumbar fusion include any of the following. 
A patient must have at least 1 of the following: 
1. Radiographic or clinical evidence of instability due to any 1 of the following: 
a. Congenital deformities, 
b. Trauma, 
c. Fractures, 
d. Chronic degenerative conditions, 
e. Tumor, 
f. Infection, 
g. Erosive conditions, 
h. Space-occupying lesions, or 
i. Iatrogenic causes, including expected instability as a consequence of another medically necessary spine 
procedure.  
If more than 1 level is fused under this indication, the record must reflect that each fused level is affected by 1 
of the above conditions. 
 
2. Symptomatic spinal deformity (in the absence of instability or neural compression) which meets the 
following criteria: Both of the first 2 criteria must be met: 
a. Functional limitation in daily activities due to back pain or discomfort and 
b. Nonresponse to at least 1 year of non-operative treatment 
Any 1 of these 3 criteria must be met: 
c. Sagittal or coronal imbalance by at least 5 cm as measured on radiographic imaging of the entire spine, or 
d. Progression of deformity by at least 10 degrees, or 
e. Scoliotic curvature of greater than 30 degrees 
 
3. Revision surgery for pseudarthrosis following an initial spine surgery if the following conditions are all met. 
a. The patient had a period of reduced pain initially following surgery and 
b. The time since the prior surgery has been at least 1 year and 
c. There is clear radiographic evidence of pseudarthrosis and 
d. The patient has exhausted available conservative treatment measures 
 
The medical record must clearly reflect which conservative treatments the patient has tried or is not a candidate 
for and why, including medical therapies, physical and exercise therapies and injections. Outcomes for fusion 
in revision surgery, usually do not lead to pain relief and as such fusion is considered a last resort treatment 
option only when all other treatment options have failed. This information must be communicated to the patient 
prior to surgery to allow for appropriate shared decision making with a well-informed patient. The medical 
record must reflect that this counseling was done and that the patient wished to undergo surgery with the 
appropriately informed consent. 
 
4. Symptomatic compression of neural elements for which disc excision is necessary for decompression. The 
record must reflect disc compression of neural elements for each level fused based on this indication. 
 
You can find this information in the Local Coverage Determination (LCD): Lumbar Spinal Fusion (L37848). 
 
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.