Cervical Fusion with Disc Removal Checklist

Published 08/06/2024

Cervical fusion is a surgical procedure that may relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness, and tingling. Hospital outpatient department (HOPD) providers will need to obtain prior authorization (PA) for cervical fusion with disc removal if performed in a HOPD setting and billed with the following CPT® codes.

Code Description
22551 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2
22552 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace

Please see the Cervical Fusion (L39773) Local Coverage Determination (LCD) or more information. Documentation requirements for cervical fusion include:

Cervical Fusion  Yes  No
Documentation to support cervical fusion surgery for the decompression of symptomatic cervical nerve root impingement. (All the following in this section must be met):

 

 
Documentation to support persistent or recurrent moderate to severe arm pain present for a minimum of 12 weeks within the current episode of neck pain with failure to respond to multimodal conservative management.  

 
Documentation to support nerve compression negatively impacts activities of daily living (ADL).

 

 
Documentation to support that all other sources of pain have been excluded.

 

 
Imaging (MRI or CT) present and supports central, lateral recess or foraminal stenosis at corresponding level with clinical signs and symptoms and include at least one of the following:

 

 
  • Cervical degenerative disc disease as indicated by the presence of 1 or more of the following findings: herniated nucleus pulposus, narrowing of the intervertebral disc, disc osteophytes, facet hypertrophy, or synovial cysts

 

 
  • Tumors (primary or metastatic)

 

 
  • Post-infection radiographic findings

 

 
  • 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

 

 

Documentation to support cervical fusion surgery for the decompression of symptomatic cervical canal stenosis. (All the following in this section must be met.)

 

 
Documentation to support persistent or recurrent moderate to severe arm pain present for a minimum of 12 weeks within the current episode of neck pain with failure to respond to multimodal conservative management. or nerve compression negatively impacts ADLs OR spastic gait, loss of manual dexterity, problems with sphincter control?    
Documentation to support that all other sources of pain/neurological deficits have been excluded.    
Imaging (MRI or CT) present and supports evidence of central stenosis at the corresponding level with clinical signs and symptoms and include one of the following:    
  • Cervical degenerative disc disease as indicated by the presence of 1 or more of the following findings: herniated nucleus pulposus, narrowing of the intervertebral disc, disc osteophytes, facet hypertrophy, and/or synovial cysts
    
  • Congenital short pedicles

 

 
  • Tumors: primary or metastatic

 

 
  • Post-infection imaging findings
    
  • Ossification of the posterior longitudinal ligament

 

 
  • Spinal instability as defined by subluxation or translation more than 3.5 mm on static lateral views and/or dynamic radiographs, or sagittal plane angulation of more than 11 degrees between adjacent segments
    
  • Cord compression with or without increased cord signal
    
Documentation to support cervical fusion surgery is being requested for the decompression or stabilization of the cervical spine.    
  • Traumatic injuries including fractures, dislocations, fracturedislocations, or traumatic ligamentous disruption

 

 
  • Spinal tumors involving the spine or spinal canal

 

 
  • Infection involving the spine in the form of discitis, osteomyelitis, or epidural abscess

 

 
  • Deformities that include the cervical spine

 

 
  • Other cervical indication

 

 
Documentation to support substantial functional limitation (severe neck pain, difficulty ambulating, decreased ability to perform ADLs, etc.) or progression of deformity.

 

 

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