Oxford Health Plans > Medical and Administrative Policies > Cervical and Lumbar Spine Surgery
Title of Policy

Cervical and Lumbar Spine Surgery

The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Memberís plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.


Policy #: SURGERY 070.4 T2

Coverage Statement:
Policy is applicable to:

    Commercial plans

Note: For additional information on related topics, refer to:

  • Artificial Total Disc Replacement for the Spine
  • Bone Healing and Fusion Enhancement Products

Conditions of Coverage:
Benefit Type General benefits package
Referral Required
(Does not apply to non-gatekeeper products)
No
Authorization (Precertification always required for inpatient admission) Yes
Precertification with MD Review No
Site(s) of Service
(If not listed, MD Review required)
Outpatient, Inpatient

Description of Service/Assessment/Background Information:

Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy (S-310)

Cervical diskectomy or microdiskectomy, foraminotomy, laminotomy are surgical techniques in which spinal nerve root pressure is relieved by removing or decompressing the structures that are impinging on the nerve roots.

Because pressure on a nerve can cause inflammation and pain, the common goal of all of these procedures is to remove any structures that are "pinching" or obstructing the nerves. There are multiple surgical approaches that can be used to perform these procedures. During surgery, the surgeon will approach the spine by separating the soft tissues of the neck. The essentially part of these procedures is to relive pressure on the spinal cord and/or nerve roots. This can be accomplished by removing a ruptured or extruding disc (diskectomy), by partial removal of the structures covering the spinal canal (laminotomy), or by enlarging the passageway where a spinal nerve root exits the spinal canal (foraminotomy). A microdiskectomy is a diskectomy procedure performed through a small incision.

These procedures are commonly done as an outpatient or "ambulatory" status. Extended or inpatient admission would require concurrent review.

Cervical Fusion, Anterior or Posterior (S320, S-330)

Cervical fusion is a surgical technique in which the spine is stabilized by fusing together two or more of the vertebrae of the spine so that motion no longer occurs between them. Bone graft is used to augment the fusion process. In addition, instrumentation (such as plates, screws or cages) may also be employed.

As part of the procedure, bone graft is placed along the spinal canal to promote healing. The procedure may also involve supplementary instrumentation (screws, rods, or wires). The instrumentation serves to hold the spine in place while the bone graft heals. Spinal fusion minimizes motion between specific vertebral bodies and thus reduces spine flexibility.

Cervical Laminectomy (S-340)

Cervical laminectomy is a surgical procedure in which the posterior portion of the spinal canal (lamina) is removed to provide more space for the spinal cord and nerve roots.

Pressure on a nerve can cause inflammation, pain and weakness (myelopathy). In addition, to muscular weakness, myelopathy can cause problems with function. The goal of a cervical laminectomy is to remove the posterior bony structure of the spinal canal (the lamina) and thereby create more space for the spinal cord and nerve roots. During surgery, the surgeon will commonly approach the spinal canal from the back by separating the soft tissues of the neck. The essential part of this procedure is to relive pressure on the spinal cord and/or nerve roots. This is accomplished by removing the back of the spinal canal. By relieving pressure on the nerve structures, the goal of the procedure is to stop damage to the spinal cord and nerve roots and allow for as much recovery as possible.

Lumbar Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy (S-808, S-810)

Lumbar diskectomy or microdiskectomy, foraminotomy, laminotomy (single level) are surgical techniques in which spinal nerve root pressure is relieved by removing or decompressing the structures that are impinging on the nerve roots.

Because pressure on a nerve can cause inflammation and pain, the common goal of all of these procedures is to remove any structures that are "pinching" or obstructing the nerves. There are multiple surgical approaches that can be used to perform these procedures. During surgery, the surgeon will approach the spine by separating the soft tissues of the back. The essentially part of these procedures is to relive pressure on the spinal cord and/or nerve roots. This can be accomplished by removing a ruptured or extruding disc (diskectomy), by partial removal of the structures covering the spinal canal (laminotomy), or by enlarging the passageway where a spinal nerve root exits the spinal canal (foraminotomy). A microdiskectomy is a diskectomy procedure performed through a small incision.

These procedures are commonly done as an outpatient or "ambulatory" status. Extended or inpatient admission would require concurrent review.

Lumbar Fusion (S-820)

Lumbar fusion is a surgical technique in which the spine is stabilized by fusing together two or more of the vertebrae of the spine so that motion no longer occurs between them. Bone graft is used to augment the fusion process. In addition, instrumentation (such as plates, screws or cages) may also be employed.

There are multiple surgical approaches that can be used to fuse the spine. During surgery, the surgeon will approach the spine from the front (anterior approach), from the back (posterior approach) or by a combination of both. As part of the procedure, a bone graft is placed between the vertebrae to promote healing. The procedure may also involve supplementary instrumentation (plates, screws or cages). The instrumentation serves to hold the spine in place while the bone graft heals. Spinal fusion minimizes motion between specific vertebral bodies and thus reduces spine flexibility. However, most fusions involve only short segments of the spine, so the restriction in motion is limited.

Lumbar Laminectomy (S-830 ISC)

Lumbar laminectomy is a surgical procedure in which the posterior portion of the spinal canal (lamina) is removed to provide more space for the spinal cord and nerve roots.

Pressure on a nerve can cause inflammation, pain and weakness (myelopathy). In addition, to muscular weakness, myelopathy can cause problems with bowel and bladder function. The goal of a lumber laminectomy is to remove the posterior bony structure of the spinal canal (the lamina) and thereby create more space for the spinal cord and nerve roots. During surgery, the surgeon will commonly approach the spinal canal from the back by separating the soft tissues of the back. The essential part of this procedure is to relive pressure on the spinal cord and/or nerve roots. This is accomplished by removing the back of the spinal canal. By relieving pressure on the nerve structures, the goal of the procedure is to stop damage to the spinal cord and nerve roots and allow for as much recovery as possible.

Policy and Rationale:

Oxford will provide coverage for cervical diskectomy or microdiskectomy, foraminotomy, laminotomy, cervical fusion (anterior or posterior), cervical laminectomy, lumbar diskectomy or microdiskectomy, foraminotomy, laminotomy, lumbar fusion, and lumbar laminectomy when the criteria set forth in Milliman Guidelines S-310, S-320, S-330, S-340, S-808, S-810, S-820 or S-830 are met.

Treatment/Application Guidelines:

Copies of office notes outlining the Member's symptoms, the course of conservative treatment, as well as documentation of the functional limitations, if any, may be requested to document this information. In addition, if available, the results of key diagnostic studies such as MRI or CT may be requested for review.

These surgeries will be covered, and will be certified at an outpatient or inpatient site of service per the Milliman Care Guidelines outlined below, as applied by our clinical staff and the judgment of our Medical Director.

  • Cervical diskectomy or microdiskectomy, foraminotomy, or laminotomy is considered to be medically necessary when one or more of the following criteria are met:

    1. Cervical radiculopathy resulting from degenerative disk disease, disk herniation, or facet joint hypertrophy if ALL of the following are present:
      • Unremitting radicular pain or progressive weakness secondary to nerve root compression
      • Failure of a full trial of nonsurgical management
    2. Cervical myelopathy resulting from spinal cord compression as evidenced by 1 or more of the following:
      • Clinical symptoms of myelopathy; examples include:
        • Clumsiness of hands
        • Urinary urgency
        • Bowel or bladder incontinence
        • Frequent falls
      • Clinical signs of myelopathy; examples include:
        • Hyperreflexia
        • Hoffmann sign
        • Increased tone or spasticity
        • Loss of thenar or hypothenar eminence
        • Gait abnormality
        • Positive Babinski sign
      • Diagnostic imaging positive for cord compression from either herniated disk or osteophyte
    3. Injury with 1 or more of the following cervical spine findings:
      • Cervical instability (in conjunction with stabilizing procedure)
      • Foreign bodies
      • Bony fracture fragments
      • Epidural hematoma
    4. Cervical spine tumors causing cord compression
    5. Cervical spine infection

  • Cervical fusion, anterior, with or without instrumentation is considered to be medically necessary when one or more of the following criteria are met:

    1. Unstable traumatic anterior column fracture, especially burst fracture
    2. Disk herniation with radiculopathy when ALL of the following are present
      • Unremitting radicular pain or progressive weakness secondary to nerve root compression
      • Failure of a full trial of nonsurgical management
    3. Multilevel spondylotic myelopathy, as evidenced by 1 or more of the following
      • Clinical symptoms of myelopathy; examples include:
        • Clumsiness of hands
        • Urinary urgency
        • Bowel or bladder incontinence
        • Frequent falls
      • Clinical signs of myelopathy; examples include:
        • Hyperreflexia
        • Hoffmann sign
        • Increased tone or spasticity
        • Loss of thenar or hypothenar eminence
        • Gait abnormality
        • Positive Babinski sign
      • Diagnostic imaging positive for cord compression from either herniated disk or osteophyte
    4. Ossification of the posterior longitudinal ligament at 1 to 3 levels associated with myelopathy
    5. Degenerative cervical spondylosis with kyphosis causing cord compression
    6. Traumatic disk herniation associated with myelopathy
    7. Primary or metastatic tumor causing pathologic fracture, cord compression, or instability
    8. Spinal infectious disease
    9. Multilevel spondylotic radiculopathy
    10. Degenerative spinal segment adjacent to a prior decompressive or fusion procedure with 1 or more of the following :
      • Symptomatic myelopathy corresponding to the adjacent level
      • Symptomatic radiculopathy corresponding to the adjacent level and unresponsive to conservative care
    11. Other symptomatic instability or cord or root compression requiring anterior fusion with ALL of the following
      • Patient unresponsive to conservative therapy (eg, rest, medication, cervical collar)
      • Imaging study demonstrating corresponding pathologic anatomy

  • Cervical fusion, posterior, with or without instrumentation is considered to be medically necessary when one or more of the following criteria are met:

    1. As a concurrent stabilization procedure with corpectomy, laminectomy, or other procedure at the cervicothoracic junction, ie, C7 and T1.
    2. As a concurrent stabilization procedure with a laminectomy, especially at C2
    3. Symptomatic pseudoarthrosis from a prior procedure
    4. Subluxation, compression in rheumatoid arthritis
    5. Multilevel spondylotic myelopathy without kyphosis, ] as evidenced by 1 or more of the following:
      • Clinical symptoms of myelopathy; examples include:
        • Clumsiness of hands
        • Urinary urgency
        • Bowel or bladder incontinence
        • Frequent falls
      • Clinical signs of myelopathy; examples include:
        • Hyperreflexia
        • Hoffmann sign
        • Increased tone or spasticity
        • Loss of thenar or hypothenar eminence
        • Gait abnormality
        • Positive Babinski sign
      • Diagnostic imaging positive for cord compression from either herniated disk or osteophyte
    6. Unstable injury; examples include:
      • Atlas and axis fractures
      • Disruption of posterior ligamentous structures
      • Facet fractures with dislocation
      • Bilateral locked facets
      • Central cord syndrome with multisegment injury
    7. Symptomatic cervical spondylosis with instability, as evidenced radiographically by 1 or more of the following:
      • Subluxation or translation of more than 3.5 mm on static lateral views or dynamic radiographs
      • Sagittal plane angulation of more than 11 degrees between adjacent segments
      • More than 4 mm of motion (subluxation) between the tips of the spinous processes on dynamic views
    8. Klippel-Feil syndrome
    9. Cervical instability in Down syndrome
    10. Cervical instability in skeletal dysplasia or connective tissue disorders
    11. Spinal tumor with associated cord compression or instability
    12. Other symptomatic instability or cord or root compression requiring posterior fusion with ALL of the following :
      • Patient unresponsive to conservative therapy (eg, rest, medication, cervical collar)
      • Imaging study demonstrating corresponding pathologic anatomy

  • Cervical laminectomy is considered to be medically necessary when one or more of the following criteria are met:

    1. Myelopathy secondary to cervical spondylopathy at 3 or more levels, as evidenced by 1 or more of the following):
      • Clinical symptoms of myelopathy; examples include:
        • Clumsiness of hands
        • Urinary urgency
        • Bowel or bladder incontinence
        • Frequent falls
      • Clinical signs of myelopathy; examples include:
        • Hyperreflexia
        • Hoffmann sign
        • Increased tone or spasticity
        • Loss of thenar or hypothenar eminence
        • Gait abnormality
        • Positive Babinski sign
      • Diagnostic imaging positive for cord compression
    2. Ossification of the posterior longitudinal ligament at 3 or more levels
    3. Degenerative spondylolisthesis (in conjunction with a posterior fusion procedure for stabilization)
    4. Congenital cervical stenosis with an anteroposterior canal diameter of 10 mm or less
    5. Cord compression due to rheumatoid arthritis (in conjunction with posterior fusion procedure for stabilization). See Cervical Fusion, Posterior guideline.
    6. Biopsy or excision of spinal lesions (eg, neoplasm, arteriovenous malformation)
    7. Epidural abscess
    8. Traumatic injury

  • Lumbar diskectomy or microdiskectomy, foraminotomy, or laminotomy is considered to be medically necessary when one or more of the following criteria are met:

    1. Rapidly progressive neurologic findings with imaging evidence of pathology that correlates with clinical findings
    2. Elective surgery needed as indicated by ALL of the following being present:
      • Herniated disk with ALL of the following:
        • Nerve or spinal cord impingement seen on imaging studies
        • Clinical findings consistent with impingement
      • All major psychosocial and substance abuse issues have been addressed.
      • Severe symptoms or findings that have not improved after at least 6 weeks of conservative therapy, including 1 or more of the following:
        • Severe disabling radiculopathy
        • Clinical findings of nerve root compromise

  • Lumbar fusion is considered to be medically necessary when one or more of the following criteria are met:

    1. Spinal fracture with 1 or more of the following:
      • Spinal instability
      • Neural compression
    2. Lumbar spinal stenosis with ALL of the following:
      • Associated lumbar spondylolisthesis
      • 1 or more of the following:
        • Progressive or severe symptoms of neurogenic claudication
        • Back pain, neurogenic claudication symptoms, or radicular pain associated with ALL of the following :
          • Significant functional impairment
          • Listhesis demonstrated on plain x-rays
          • Central, lateral recess or foraminal stenosis demonstrated on imaging (eg, MRI, CT, myelography)
          • Failure of at least 3 months of conservative care
    3. Spondylolysis with 1 or more of the following:
      • Progressive spondylolisthesis with neurologic compromise
      • Spondylolisthesis with ALL of the following:
        • High-grade (ie, 50% or more anterior slippage) spondylolisthesis demonstrated on plain x-rays
        • Back pain, neurogenic claudication symptoms, or radicular pain from lateral recess or foraminal stenosis
        • Significant functional impairment
        • Failure of at least 3 months of conservative care
    4. Spinal repair (if needed) in operations for 1 or more of the following:
      • Dislocation
      • Abscess
      • Tumor
    5. Severe degenerative scoliosis with 1 or more of the following:
      • Progression of deformity to greater than 50 degrees with loss of function
      • Persistent significant radicular pain or weakness unresponsive to conservative care
      • Persistent neurogenic claudication unresponsive to conservative care
    6. Spinal tuberculosis

  • Lumbar laminectomy is considered to be medically necessary when one or more of the following criteria are met:

    1. Rapidly progressive neurologic finding of spinal cord compression, with imaging evidence of pathology that correlates with clinical findings
    2. Cauda equina syndrome with ANY ONE of the following:
      • Bowel dysfunction
      • Bladder dysfunction
      • Saddle anesthesia
      • Bilateral lower extremity neurologic abnormalities
    3. Spinal stenosis with ANY ONE of the following:
      • Progressive or severe symptoms of neurogenic claudication
      • Leg or buttock symptoms, with or without back pain, that are ALL of the following:
        • Persistent and disabling
        • Correlated with spinal stenosis on imaging
        • Unresponsive to 3 months of conservative therapy
    4. Spondylolisthesis with ANY ONE of the following:
      • Progressive or severe neurologic deficits
      • Back pain, neurogenic claudication symptoms, or radicular pain from lateral recess or foraminal stenosis associated with ALL of the following:
        • Significant functional impairment
        • Listhesis demonstrated on plain x-rays
        • Failure of 3 months of conservative care
      • Spinal stenosis that is severe and disabling or unresponsive to 3 months of conservative care
    5. Epidural compression due to tumor, hemangioma, or metastatic neoplasm
    6. Centrally herniated disks
    7. Herniated disk fragment with nerve root impingement
    8. Acute trauma
    9. Epidural abscess
    10. Conus medullaris and cauda equina compression from neoplasms or benign cystic lesions

    Payment Guidelines:

    Applicable CPT Codes:

    Code Description
    22207 Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, 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
    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 (List separately in addition to code for primary procedure)
    22526 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level
    22527 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure)
    22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar
    22534 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure)
    22548 Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process
    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 (List separately in addition to code for separate procedure)
    22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2
    22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar
    22585 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)
    22590 Arthrodesis, posterior technique, craniocervical (occiput-C2)
    22595 Arthrodesis, posterior technique, atlas-axis (C1-C2)
    22600 Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment
    22610 Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed) (Effective 1.1.2012)
    22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)(Effective 1.1.2012)
    22614 Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (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
    (Effective 1/1/2012)
    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 and segment; lumbar
    22634
    (Effective 1/1/2012)
    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 and segment; each additional interspace and segment (List separately in addition to code for primary procedure)
    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
    22818 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments
    22819 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segments
    22830 Exploration of spinal fusion
    22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary proc
    22841 Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure)
    22842 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)
    22843 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure)
    22844 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure)
    22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)
    22846 Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure)
    22847 Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure)
    22849 Reinsertion of spinal fixation device
    22850 Removal of posterior nonsegmental instrumentation (eg, Harrington rod)
    22851 Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure)
    22852 Removal of posterior segmental instrumentation
    22855 Removal of anterior instrumentation
    22861 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical
    22862 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar
    22899 Unlisted procedure, spine
    63001 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical
    63005 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis
    63012 Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)
    63015 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; cervical
    63017 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar
    63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical
    63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar
    63035 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure)
    63040 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical
    63042 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar
    63043 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (List separately in ad
    63044 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace (List separately in addi
    63045 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical
    63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar
    63048 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or
    63050 Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments;
    63051 Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices (eg, wire, suture, mini-
    63056 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)
    63057 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure)
    63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace
    63076 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure)
    63180 Laminectomy and section of dentate ligaments, with or without dural graft, cervical; 1 or 2 segments
    63182 Laminectomy and section of dentate ligaments, with or without dural graft, cervical; more than 2 segments
    63185 Laminectomy with rhizotomy; 1 or 2 segments
    63190 Laminectomy with rhizotomy; more than 2 segments
    63191 Laminectomy with section of spinal accessory nerve
    63194 Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 stage; cervical
    63196 Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage; cervical
    63198 Laminectomy with cordotomy with section of both spinothalamic tracts, 2 stages within 14 days; cervical
    63200 Laminectomy, with release of tethered spinal cord, lumbar
    63250 Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; cervical
    63252 Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar
    63265 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical
    63267 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar
    63270 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical
    63272 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar
    63275 Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical
    63277 Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar
    63280 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, cervical
    63282 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar
    63285 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical
    63287 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracolumbar
    63290 Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural lesion, any level

    References:

    1. Milliman Care Guidelines, 13th Edition. Lumbar Fusion - Annotated Bibliography and Surgical Care Guidelines.

    2. American Medical Association. Current Procedural Terminology: CPT, Professional Edition. AMA Press.

    Effective Date: December 1, 2011