Subject: Medical Coverage Policy 0527 Cervical Fusion
Dear Dr. Kessel,
The American Association of Neurological Surgeons (AANS), Congress of Neurological Surgeons (CNS)
and the AANS/CNS Joint Section on Disorders of Spine and Peripheral Nerves (DSPN) appreciate the
opportunity to provide our comments on the Cigna Medical Coverage Policy 0527 Cervical Fusion. The
policy discussion is well done and provides a good review of the extant literature. However, the
recommendations for coverage do not comply with standard spine practices or with the literature
reviewed.
We would suggest the following changes (listed in bold type):
- Page 2, CERVICAL FUSION FOR IATROGENIC INSTABILITY: Add a fourth indication,
“following extensive cervical laminectomy.”
Rationale: The literature supports the incorporation of stabilization to multi-level cervical
laminectomy procedures performed for cervical stenosis6,7 - Page 2, CERVICAL FUSION FOR INSTABILITY: SPINAL STENOSIS: Change element 2 to
read as follows: “failure of at least three (3) consecutive months of physician-supervised
conservative medical management including exercise, nonsteroidal and/or steroidal medication
(unless contraindicated), physical therapy and activity lifestyle modification in the absence of
clinically significant myelopathy.”
Rationale: The presence of significant myelopathy likely will not respond to physical
therapy, NSAIDs, lifestyle modifications, and other conservative interventions. Forcing
patients to wait for three months or greater may allow for progression of myelopathy and
lead to greater degree of permanent disability.1 - Page 3, CERVICAL FUSION NOT MEDICALLY NECESSARY: Change the first bullet to read:
“…with initial primary foraminotomy/discectomy for nerve root decompression or spinal stenosis
in the absence of spondylolisthesis or kyphosis”. Strike bullet #2, “treatment of spinal
stenosis in the absence of spondylolisthesis or spinal instability,” and bullet #4: “posterior cervical fusion performed with laminectomy in the absence of kyphosis (e.g., degenerative spine) or subluxation/translation of more than 3.5 mm.”. Rationale: the literature supports the incorporation of stabilization to multi-level cervical laminectomy procedures performed for cervical stenosis.
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Read full letter here
