Cervical Fusion with Disc Removal Best Practices

Table of Contents

• Introduction
• Coverage
• General Documentation Requirements
• Medical Necessity Criteria for Each Indication
• Limitations and Exceptions to Conservative Therapy

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Introduction

Cervical discectomy with disc removal is a surgical procedure intended to relieve spinal cord or nerve root compression, that may alleviate corresponding pain, weakness, numbness and tingling. The procedure is typically followed by a fusion surgery to ensure spinal stabilization. Three indications are considered medically necessary, provided there is sufficient documentation: decompression of symptomatic nerve root impingement, decompression of symptomatic cervical canal stenosis, and decompression or stabilization of the cervical spine.

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Coverage

Effective for dates of service 7/1/2021, and after, HOPD providers will need to obtain PA for cervical fusion with disc removal if performed in a HOPD setting and billed with the follow CPT codes.

**Code 22552 is an add on code and it must be requested with 22551**

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General Documentation Requirements

1. Clear indication of procedure(s) requested
2. Relevant medical history
3. Physical examination findings related to the cervical spine
4. Pertinent imaging reports, procedure reports, and/or progress notes

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Medical Necessity Criteria for Each Indication

Decompression of Symptomatic Cervical Nerve Root Impingement

1. Pain assessment including
   1. Persistent or recurrent moderate or severe arm pain (4 or more on the visual analog scale [VAS] or equivalent)
   2. Present for a minimum of 12 weeks within the current episode of neck pain
   3. Documented failure to respond to multimodal conservative management (as tolerated)
2. Nerve compression negatively impacts ADLs AND
3. All other potential sources of pain/neurological deficit have been excluded AND
4. Imaging (MRI or CT) evidence of central, lateral recess or foraminal stenosis at the level corresponding with clinical myotome signs or symptoms and including at least one of the following:
   1. Cervical degenerative disc disease as indicated by the presence of one or more of the following findings: herniated nucleus pulposus, narrowing of the intervertebral disc, disc osteophytes, facet hypertrophy, or synovial cysts.
   2. Tumors (primary or metastatic)
   3. Post-infection radiographic findings
   4. Spinal instability as defined by subluxation or translation more than 3.5 mm on static lateral views or dynamic radiographs OR sagittal plane angulation of more than 11 degrees between adjacent segments.

Decompression of Symptomatic Cervical Canal Stenosis

1. Pain assessment including
   1. Persistent or recurrent moderate or severe arm pain (4 or more on the visual analog scale or equivalent)
   2. Present for a minimum of 12 weeks within the episode of arm pain
   3. Documented failure to respond to multimodal conservative management (as tolerated) OR
2. Nerve compression that negatively impacts activities of daily living OR
3. Spastic gait, loss of manual dexterity, problems with sphincter control, AND
4. All other potential sources of pain/neurological deficit have been excluded AND
5. Imaging (MRI or CT) evidence of central stenosis at the level corresponding with clinical signs or symptoms and including at least one of the following:

1. Cervical degenerative disc disease as indicated by the presence of one or more of the following findings: herniated nucleus pulposus, narrowing of the intervertebral disc, disc osteophytes, facet hypertrophy, or synovial cysts.
2. Congenital short pedicles
3. Tumors (primary or metastatic)
4. Post infection radiographic findings
5. Ossification of the posterior longitudinal ligament.
6. Spinal instability as defined by subluxation or translation more than 3.5 mm on static lateral views or dynamic radiographs OR sagittal plane angulation of more than 11 degrees between adjacent segments.
7. Cord compression with or without increased cord signal.

Decompression or Stabilization of the Cervical Spine

All medical necessity criteria must be fulfilled for each of the following indications as listed.

1. Traumatic injuries including fractures, dislocations, facture-dislocations, or traumatic ligamentous disruption when:
   1. Fractures or dislocations are likely to result in spinal instability without neurological defects OR
   2. Fractures or dislocations associated with neurological defects are present at the affected level OR
   3. Instability is present.

2. Spinal tumors involving the spine or spinal canal when:
   1. Malignant or benign tumors which have caused instability or neurologic deficit where treatment of the tumor will likely require stabilization of the spine. OR
   2. Expected treatment of the tumor whether by chemotherapy or radiation therapy or surgery will likely cause spinal instability or neurologic deficits. OR
   3. Instability is present.
3. Infection involving the spine in the form of discitis, osteomyelitis, or epidural abscess when:
   1. Imaging or other studies (MRI, biopsy, bone aspirate) demonstrating infection AND
   2. Imaging evidence of vertebral body destruction OR documentation that spinal debridement will cause vertebral instability OR
   3. Instability is present.

4. Deformities that include the cervical spine when:

1. Cervical kyphosis associated with cord compression or atlantoaxial (C1-C2) subluxation or basilar invagination of the odontoid process into the foramen magnum; or subaxial (C2-T1) instability kyphosis, head drop syndrome, post-laminectomy deformity are present OR
2. Symptomatic pseudarthrosis (non-union of prior fusion) with radiological demonstration (e.g., CT or MRI) of non-union of prior fusion (lack of bridging bone or abnormal motion at fused segment) after 12 months since fusion surgery or with radiographic evidence of hardware failure (fracture or displacement) is present OR
3. Spinal instability is present after laminectomy OR
4. Rheumatoid arthritis with associated instability is present OR
5. Cervical degenerative spondylolisthesis with spinal instability (Anterolisthesis/Posterolisthesis) is present AND
6. Substantial functional limitation is present such as severe neck pain, difficulty ambulating and decrease ability to perform ADLs or ability to maintain forward gaze OR
7. Progression of deformity is present.

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Limitations and Exceptions to Conservative Therapy

For decompression of symptomatic cervical nerve root impingement AND cervical canal stenosis:​​​​

1. Isolated chronic axial cervical pain is not considered reasonable and necessary.
2. Exceptions to conservative therapy policy requirements for:
   • A diagnosis of cervical myelopathy:
     • Class III or above, OR
       • Class IIIA – Objective weakness with long-tract signs; remains ambulatoryx
       • Class IIIB – Objective weakness with long-tract signs; non-ambulatory and quadriparetic
     • Progression of neurological deficits during the trial of conservative treatment
   • A diagnosis of cervical radiculopathy:
     • Progressive motor weakness, OR
     • Significant motor weakness that interferes with ADLs, OR
   • Severe radicular pain that limits ability to perform ADLs
     • >7/10 pain on a VAS or equivalent, AND
     • Associated with confirmatory imaging (CT/MRI) and clinical radiological correlation
   • Cauda Equina syndrome

For cervical canal stenosis ONLY

1. Asymptomatic myelopathy is not considered reasonable and necessary.

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Revised 10/29/2024​​​