Subject: BCBSM Policy on Minimally Invasive Lumbar Interbody Fusion
Dear Dr. Simmer:
On behalf of the American Association of Neurological Surgeons (AANS), the Congress of
Neurological Surgeons (CNS), and our AANS/CNS Joint Section on Disorders of the Spine and
Peripheral Nerves, we would like to thank Blue Cross-Blue Shield of Michigan for the opportunity to
comment on the BCBSM medical policy BCBSM Minimally Invasive Lumbar Interbody Fusion. We
appreciate the efforts of your team in developing a review of the published literature reporting on the use
of minimally invasive procedures for lumbar interbody fusion such as lateral interbody fusion (e.g.,
extreme lateral lumbar interbody fusion or XLIF, direct lateral lumbar interbody fusion or DLIF), but
disagree that such interventions are considered experimental and investigational, and not medically
necessary.
We believe that minimally invasive lateral interbody fusion (e.g., XLIF, DLIF) with direct
visualization is a medically necessary option in appropriate patients with medical indications as
determined by their treating physician. There is a distinction between percutaneous procedures, in
which the surgeon is unable to directly visualize the anatomy being operated on with the naked eye, with
minimally invasive (MIS) procedures, which are open procedures using specialized retractors, such as
muscle-dilating retractor systems, to allow direct visualization of the spinal structures. Open, or direct
visualization, lateral interbody fusion procedures are reported with the appropriate CPT code:
- CPT 22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare
interspace (other than for decompression); lumbar
Lateral lumbar interbody fusion fusions are accomplished by direct visualization of the bony anatomy and
the neural elements, whether by exposures with traditional retractors or by muscle dilating minimal
access retractors, which may be considered equivalent. In both of these instances, the same anatomy,
i.e., vertebral body, disc space, psoas muscle, etc., are directly visualized for the procedure. This is
distinct from percutaneous techniques, where the procedure is performed with fluoroscopy or
image guided systems without direct visualization of the anatomy. The evidence to support
minimally invasive techniques as a viable alternative to traditional open procedures continues to
accumulate in the literature.
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