![]() ![]() Repair of open spinal dysraphism, or radiographically demonstrated closed spinal dysraphism (including tethered cord) with significant signs or symptoms of lumbosacral spinal dysfunction or in asymptomatic young children who are not yet toilet trained or have not yet begun to walk.Spinal stenosis (central, lateral recess or foraminal stenosis) graded as moderate, moderate to severe or severe (not mild or mild to moderate) with unremitting pain, with stenosis confirmed by imaging studies (e.g., CT or MRI) at the level corresponding to neurological findings, where symptoms have failed to respond to six weeks conservative therapy Footnote1* (unless there is evidence of cord compression, or other indications for waiver of requirements for conservative management, noted below) or.Synovial cysts, Tarlov cysts (also known as perineurial cysts and sacral meningeal cysts), or arachnoid cysts causing spinal cord or nerve root compression with unremitting pain, confirmed by imaging studies (e.g., CT or MRI) and with corresponding neurological deficit, where symptoms have failed to respond to six weeks of conservative therapy Footnote1* (unless there is evidence of cord compression, or other indications for waiver of requirements for conservative management, noted below) or.Epidural hematomas confirmed by imaging studies (e.g., CT or MRI) or.Spinal tumor confirmed by imaging studies (e.g., CT or MRI) or.Spinal infection confirmed by imaging studies (e.g., CT or MRI) or.Spinal fracture, dislocation (associated with mechanical instability), locked facets, or displaced fracture fragment confirmed by imaging studies (e.g., CT or MRI) or. ![]() Member has failed at least 6 weeks of conservative therapy Footnote1* (unless there is evidence of spinal cord compression or other indications for waiver of requirements for conservative management, noted below) andĬervical, thoracic, lumbar, or sacral laminectomy for any of the following:.Member has signs or symptoms of neural compression (radiculopathy, neurogenic extremity claudication, myelopathy) associated with the levels being treated and.Lumbar laminectomy for individuals with a herniated disc when all of the following criteria are met: Member has failed at least 6 weeks of conservative therapy Footnote1* (unless there is evidence of thoracic cord compression, or other indications for waiver of requirements for conservative management, noted below) an d.All other reasonable sources of pain and/or neurological deficit have been ruled out and.Thoracic laminectomy (and/or thoracic discectomy and fusion) for individuals with herniated discs or other causes of thoracic nerve root compression (osteophytic spurring, ligamentous hypertrophy) when all of the following criteria are met: Member's activities of daily living are limited by symptoms of neural compression.Member has failed at least 6 weeks of conservative therapy Footnote1* (unless there is evidence of cervical cord compression or other indications for waiver of requirements for conservative management, noted below) and.Imaging studies (e.g., CT or MRI) indicate central/lateral recess or foraminal stenosis (graded as 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.Member has signs or symptoms of neural compression (radiculopathy, neurogenic claudication, myelopathy) associated with the levels being treated and.All other reasonable sources of pain and/or neurological deficit have been ruled out and.This Clinical Policy Bulletin addresses spinal surgeries.Īetna considers the following medically necessary:Ĭervical laminectomy (and/or an anterior and/or posterior cervical discectomy and fusion) or cervical laminoplasty for individuals with herniated discs or other causes of spinal cord or nerve root compression (osteophytic spurring, ligamentous hypertrophy) when all of the following criteria are met: Number: 0743 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References ![]()
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