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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 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. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L37848: Lumbar Spinal Fusion. 
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.