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Deformity Surgery - CAM 399HB

Purpose
This guideline covers the surgical indications for adult spinal deformity. Whenever possible, spinal deformity in adults is treated non-operatively.

Scope
Spinal surgeries should be performed only by those with extensive surgical training (neurosurgery, orthopedic surgery). Choice of surgical approach is based on anatomy, pathology, and the surgeon's experience and preference.

Instrumentation, bone formation or grafting materials, including biologics, should be used at the surgeon’s discretion; however, use should be limited to FDA approved indications regarding the specific devices or biologics.

All surgery requests to treat adult deformity will be reviewed on a case-by-case basis. Operative treatment is indicated when the natural history of surgically treated lesions is better than the natural history for non-operatively treated lesions. All operative interventions must be based on a positive correlation with clinical findings, the natural history of the disease, the clinical course, and diagnostic tests or imaging results. All individuals being considered for surgical intervention should receive a comprehensive neuromusculoskeletal examination to identify pain generators that may either respond to non-surgical techniques or may be refractory to surgical intervention.

Policy

INDICATIONS
Thoracic Deformity (Minimal/Secondary/Flexible Lumbar Involvement) in Adults

  • When ALL the following criteria are met (1,2,3):
    • Individual has significant pain or symptoms that impairs daily activities for ≥ 6 months
    • Failure of symptom or pain improvement upon completion of at least 12 weeks of focused non-operative therapy/rehabilitation* in the past year
    • Imaging studies confirm spinal curvature and demonstrate at least one of the following:
      • Spinal curvature > 75 degrees (kyphosis); 
      • Severe kyphosis (chin-brow vertical angle greater than 35 degrees).

Lumbar Deformity (With or Without Secondary Thoracic Involvement) in Adults

  • When ALL the following criteria are met (1,2,3):
    • Lumbar back pain, neurogenic claudication, and/or radicular leg pain without significant motor deficit (0-3/5) that impairs daily activities for at least 6 months
    • Failure of symptom or pain improvement upon completion of at least 12 weeks of focused non-operative therapy/rehabilitation* in the past year
    • Imaging studies that correspond to clinical findings and show at least one of the following:
      • Sagittal or coronal imbalance of at least 5 cm measured on long plate standing x-rays of the entire spine
      • A fixed scoliosis of at least 40 degrees

*Non-Operative Care (1,2,4,5,6)

  • Documented failure of at least twelve (12) consecutive weeks in the past year of any 2 of the following physician-directed conservative treatments:
    • Analgesics, steroids, and/or NSAIDs
    • Structured program of physical therapy aimed at increasing core muscle strength
    • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician
    • Epidural steroid injections and or facet injections/selective nerve root block

Relative Contraindications for Spine Surgery
NOTE: Cases may not be approved if the below contraindications exist:

  • Medical contraindications to surgery. (e.g., osteoporosis; infection of soft tissue adjacent to the spine, whether or not it has spread to the spine; severe cardiopulmonary disease; anemia; malnutrition and systemic infection) (7,8,9)
  • Psychosocial risk factors. It is imperative to rule out non-physiologic modifiers of pain presentation or non-operative conditions mimicking radiculopathy or instability (e.g., peripheral neuropathy, piriformis syndrome, myofascial pain, sympathetically mediated pain syndromes, sacroiliac dysfunction, psychological conditions, etc.) prior to consideration of elective surgical intervention. (8,10) Individuals with clinically significant depression or other psychiatric disorders being considered for elective spine surgery will be reviewed on a case-by-case basis and the surgery may be denied for risk of failure.
  • Active Tobacco or Nicotine use prior to fusion surgery. Individuals must be free from smoking and/or nicotine use for at least six weeks prior to surgery and during the entire period of fusion healing. (11,12)
  • Morbid Obesity. Contraindication to surgery in cases where there is significant risk and concern for improper post-operative healing, post-operative complications related to morbid obesity, and/or an inability to participate in post-operative rehabilitation. (13,14) These cases will be reviewed on a case-by-case basis and may be denied given the risk of failure.

References:

  1. Charles Y, Ntilikina Y. Scoliosis surgery in adulthood: what challenges for what outcome?. Annals of Translational Medicine. 2020; 8: 34-34. 10.21037/atm.2019.10.67. 
  2. North American Spine Society. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Low Back Pain. NASS. 2021; 2022: https://www.spine.org/Portals/0/assets/downloads/ResearchClinicalCare/Guidelines/LowBackPain.pdf. 
  3. Ghandhari H, Ameri E, Nikouei F, Mahdavi S, Chehrassan M. Selective Thoracolumbar/Lumbar Fusion in Adolescent Idiopathic Scoliosis: A Comprehensive Review of the Literature. The Archives of Bone and Joint Surgery. 2023; 11: 313-320. 10.22038/abjs.2022.61439.3014. 
  4. Glassman S, Berven S, Shaffrey C, Mummaneni P, Polly D. Commentary: Appropriate Use Criteria for Lumbar Degenerative Scoliosis: Developing Evidence-based Guidance for Complex Treatment Decisions. Neurosurgery. 2017; 80: E205-E212. 10.1093/neuros/nyw094. 
  5. Laverdière C, Georgiopoulos M, Ames C, Corban J, Ahangar P et al. Adult Spinal Deformity Surgery and Frailty: A Systematic Review. Global Spine Journal. 2022; 12: 689-699. 10.1177/21925682211004250. 
  6. Neuman B, Baldus C, Zebala L, Kelly M, Shaffrey C et al. Patient Factors That Influence Decision Making. SPINE. 2016; 41: E349-E 358. 10.1097 /BRS.0000000000001222.
  7. Puvanesarajah V, Shen F, Cancienne J, Novicoff W, Jain A et al. Risk factors for revision surgery following primary adult spinal deformity surgery in patients 65 years and older. J Neurosurg Spine. 2016; 25: 486-493. 10.3171/2016.2.Spine151345. 
  8. Rajaee S, Kanim L, Bae H. National trends in revision spinal fusion in the USA: patient characteristics and complications. Bone Joint J. 2014; 96-b: 807-816. 10.1302/0301-620x.96b6.31149. 
  9. Varshneya K, Jokhai R T, Fatemi P, Stienen M N, Medress Z A et al. Predictors of 2-year reoperation in Medicare patients undergoing primary thoracolumbar deformity surgery. J Neurosurg Spine. 2020; 1-5. 10.3171/2020.5.Spine191425. 
  10. North American Spine Society. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. NASS. 2011; https://www.spine.org/Portals/0/Assets/Downloads/ResearchClinicalCare/Guidelines/LumbarStenosis.pdf. 
  11. Jackson 2nd K, Devine J. The Effects of Smoking and Smoking Cessation on Spine Surgery: A Systematic Review of the Literature. Global Spine J. 2016; 6: 695-701. 10.1055/s-0036-1571285. 
  12. Nunna R, Ostrov P, Ansari D, Dettori J, Godolias P et al. The Risk of Nonunion in Smokers Revisited: A Systematic Review and Meta-Analysis. Global Spine J. 2022; 12: 526-539. 10.1177/21925682211046899. 
  13. Feeley A, McDonnell J, Feeley I, Butler J. Obesity: An Independent Risk Factor for Complications in Anterior Lumbar Interbody Fusion? A Systematic Review. Global Spine J. 2022; 12: 1894-1903. 10.1177/21925682211072849. 
  14. Cofano F, Perna G, Bongiovanni D, Roscigno V, Baldassarre B et al. Obesity and Spine Surgery: A Qualitative Review About Outcomes and Complications. Is It Time for New Perspectives on Future Researches?. Global Spine J. 2022; 12: 1214-1230. 10.1177/21925682211022313.

Coding Section

Code Number Description
CPT 22206

Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); thoracic
  22207 Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (e.g., pedicle/vertebral body subtraction); lumbar
  22208 Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment (List separately in addition to code for primary procedure)
  22210 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical
  22212 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic
  22214 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar
  22216

Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment (List separately in addition to primary procedure)
  22220 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical
  22222 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic
  22224 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar
  22226 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment
  22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumba
  22614 Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace (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; lumbar
  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
  22830 Exploration of spinal fusion

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2025 Forward

10/01/2025 New Policy. 
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