Procedure Codes and Description
Group 1 Codes:
22533 ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR
22534 ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC OR LUMBAR, EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22558 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR
22585 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22612 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)
22614 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22630 ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE; LUMBAR
22632 ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22633 ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE AND SEGMENT; LUMBAR
22634 ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE AND SEGMENT; EACH ADDITIONAL INTERSPACE AND SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
22800 ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; UP TO 6 VERTEBRAL SEGMENTS
22802 ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 7 TO 12 VERTEBRAL SEGMENTS
22804 ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 13 OR MORE VERTEBRAL SEGMENTS
22808 ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 2 TO 3 VERTEBRAL SEGMENTS
22810 ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 4 TO 7 VERTEBRAL SEGMENTS
22812 ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 8 OR MORE VERTEBRAL SEGMENTS
Background:
Initial management of low back pain can include rest, exercise program, avoidance of activities that aggravate pain, application of heat/cold modalities, pharmacotherapy, local injections, lumbar bracing, chiropractic manipulation, and physical therapy. When conservative therapy (non-surgical medical management) is unsuccessful after at least 3 to 12 months, depending on the diagnosis, lumbar spinal fusion (arthrodesis) may be considered for certain conditions.
This policy does not address:
Acute spinal fracture or 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 from idiopathic scoliosis over 40 degrees.
Progressive degenerative scoliosis
Surgical techniques to achieve lumbar spinal fusion are numerous, and include different surgical approaches (anterior, posterior, lateral) to the spine, different areas of fusion (intervertebral body,interbody), transverse process (posterolateral), different fusion materials (bone graft and/or metal instrumentation), and a variety of ancillary techniques to augment fusion.
Indications
Spinal stenosis for a single level (for example, L4-L5) with associated spondylolisthesis and symptoms of spinal claudication and radicular pain. These patients with associated spondylolisthesis can also have motor deficit and / or described (non-iatrogenic or iatrogenic) instability on pre-operative flexion and extension radiographs. 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.
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 (slippage at 26% or greater)
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.
Spondylolysis demonstrated on imaging studies (e.g., CT scan, MRI, bone scan, or discography) as the likely cause of pain.
Repeat lumbar fusion following prior fusion for associated spondylolisthesis (for example anterolisthesis) with all the following:
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
Patient had some relief of pain symptoms following the prior spinal surgery.
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:
Imaging studies confirm evidence of pseudoarthrosis (e.g., radiographs, CT)
Unsuccessful improvement despite 3 months of clinically appropriate post-operative nonsurgical medical management
Patient had some relief of pain symptoms following the prior spinal surgery.
Limitations
Initial lumbar spinal fusion for degenerative disease of the lumbar spine is not considered medically necessary and is noncovered:
When performed with initial primary laminectomy/discectomy for nerve root decompression or spinal stenosis, without documented spondylolisthesis and/or spondylolysis.
***Spondylolishthesis and/or spondylolysis must be confirmed with appropriate pre-operative diagnostic imaging (e.g., plain film, CT, MRI, discography, bone scan, and/or gallium scan).
Percutaneous sacrioiliac minimally invasive joint stabilization for arthodesis (27279) can be indicated for the treatment of sacro-iliac joint (SIJ) pain for patients with low back/buttock pain who meet all of the following criteria:
* Diagnostic imaging studies that include all of the following:
plain radiographs and a CT or MRI of the SI joint that excludes the presence of destructive lesions (e.g. tumor, infection) or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion
ipsilateral hip plain radiographs to rule out osteoarthritis
lumbar spine CT or MRI to rule out neural compression or other degenerative condition that can be causing low back or buttock pain
* and, at least 80 percent reduction of pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced SIJ injection on two separate occasions
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
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Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
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ICD-10 Codes that Support Medical Necessity
ICD-10 CODE DESCRIPTION
M43.00 – M43.19 – Opens in a new window Spondylolysis, site unspecified – Spondylolisthesis, multiple sites in spine
Q76.2 Congenital spondylolisthesis