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Indicates Non-Covered Service

Anterior Cervical Decompression with Fusion (ACDF) - Single Level (elective)

Anterior Cervical Decompression with Fusion (ACDF) - Multiple Level (elective)

Back Pain - Invasive Procedures

-Aetna-

Cervical Decompression with or without Fusion

-Anthem-

Cervical Artificial Disc Replacement - Single or Two Level (elective)

Cervical Artificial Intervertebral

Disc

-Medicare-

Cervical

Fusion

-Cigna-

Cervical Fusion for Treatment of Axial Neck Pain (elective)

Cervical Laminectomy for Herniated Disc

Cervical Laminoplasty

-Aetna-

Cervical Posterior Decompression (elective)

Cervical Posterior Decompression with Fusion – Multiple levels (urgent/emergent)

Cervical Posterior Decompression with Fusion - Single Level (elective)

Referral Indications- Cervical Spine

Cervical

Spine Procedures

Coccygectomy & Treatments for Coccydynia

Discography-

Lumbar

-Aetna-

-FloridaBlue-

-Cigna-

-Humana-

Growing Rods for Spinal Surgery

Idiopathic Scoliosis Treatment

-Aetna-

Interspinous Process Decompression

-Medicare-

Intervertebral Disc Prostheses

-Aetna-

Laminectomy, Laminotomy, Facetectomy, & Foraminotomy (elective)

Laminectomy & Fusion

-Aetna-

Lumbar Laminectomy

-Anthem-

-Cigna-

-Humana-

Lumbar Discectomy/Microdisc-ectomy (elective)

-Anthem-

Lumbar Spinal Fusion

-Medicare-

Lumbar Fusion & Treatment of Spinal Deformity (including Scoliosis & Kyphosis)

Referral

Indications

Lumbar Spine

Lumbar Spinal Procedures

-FloridaBlue-

Lumbar Total Disc Arthroplasty (TDA)

-Anthem-

-Medicare-

-Anthem-

-UHC-

Multi-level Lumbar Fusions with or without decompression (elective)

Pedicle Screws for Spinal Fixation & Intervertebral Body Fusion Devices

Percutaneous Vertebral Augmentation

Percutaneous Vertebroplasty, Kyphoplasty, & Sacroplasty

-Anthem-

-FloridaBlue-

-Humana-

Recombinant Human Bone Morphogenetic Protein

-FloridaBlue-

Repeat Lumbar Spine Fusion Operations (elective)

Sacral

Nerve Stimulation

-FloridaBlue-

-Medicare-

Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint (L36406)

Sacroiliac Joint Fusion

-Anthem-

-FloridaBlue-

Sacroiliac Joint Procedures

-Cigna-

Scoliosis

& Spinal Deformity

Single Level Lumbar Fusion with or without Decompression (elective)

Spinal Decompression Surgery

-Humana-

Surgery for Spinal Deformity

-FloridaBlue-

-Medicare-

Surgical Treatment of Chest Wall Deformities

-Cigna-

Spinal Fusion Surgery-

All Levels

-Humana-

Thoracic Laminectomy and/or Thoracic Diskectomy & Fusion

Thoracic Spine Surgery

-UHC-

Thoracoscopic Sympathectomy

-Aetna-

Indicates Non-Covered Service

Automated Percutaneous Discectomy, Laser Discectomy, Percutaneous Endoscopic Discectomy, & DISC Nucleoplasty

AxiaLIF

-Aetna-

Discography

-UHC-

Dynamic Spinal Stabilization Devices

-Humana-

Epidural Lysis of Adhesions

-Humana-

-UHC-

Epiduroscopy

-UHC-

Facet

Arthroplasty

-FloridaBlue-

-Humana-

-FloridaBlue-

Interspinous & Interlaminar Stabilization/Distraction (Spacers) & Fixation (Fusion) Devices

Intradiscal Procedures

-Aetna-

Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofre-quency Annuloplasty, & Biacuplasty

Pulsed Radiofrequency

-Aetna-

Skeletal Analysis Systems

-Aetna-

Traction Devices – Cervical & Lumbar

-Aetna-

-Cigna-

Vertebral Axial Decompression

-Aetna-

-UHC-

-Cigna-

-FloridaBlue-

-Humana-

Vertebral Body Tethering for Scoliosis

-UHC-

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