Blue Cross Blue Shield of Minnesota Medical Policy


Medical Policy:
Spinal Fusion: Lumbar
Effective Date:
October 5, 2020
Issued Date:
October 5, 2020
Last Revision Date:
July 2020
Annual Review:
July 2020

This policy version was replaced on July 1, 2021. To find the newest version, go to, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

Back pain affects approximately 80% of individuals in the United States at some point in their lives. Although most patients with low back pain can be managed non-operatively, lumbar fusion may be used in certain emergent situations or in carefully selected patients with specific anatomical derangements when conservative therapy has failed. In considering surgical intervention, however, patients should receive education concerning alternative treatments, as well as the risks and benefits associated with spinal surgery. Risk factors for nonunion of a lumbar spinal fusion include, but are not limited to: use of tobacco or nicotine in any form, alcoholism, diabetes, osteoporosis, malnutrition, or repeated fusion attempts.

This policy applies to all approaches to lumbar fusion, including minimally invasive approaches, with the exception of Axial (Percutaneous) Interbody Lumbar Fusion which is addressed separately in policy #IV-91.


Osteomyelitis:  Bone infection.

Scoliosis:  Sideways curve of the spine that makes the spine look more like an "S" or "C" than a straight "I."

Cobb angle:  Measurement of the degree of side-to-side spinal curvature, as demonstrated on x-ray. This measure is used to track the progression of scoliosis.

Kyphosis:  Forward bending (curving) of the spine which produces a roundback deformity.

Pseudarthrosis:  Formation of a false joint at the site where a fractured bone has failed to heal.

Spinal instability:  >3mm of translation and/or 10 degrees or more of angulation of one vertebra compared to the adjacent vertebra in a spinal motion segment.

Spinal stenosis:  Abnormal narrowing of the spinal canal (central stenosis), lateral recess and/or neural foramina (foraminal stenosis).

Spondylolisthesis:  A forward dislocation of one vertebra over the one beneath it, producing pressure on spinal nerves.

Degenerative disc disease:  A condition involving the gradual degeneration of the intervertebral discs, also known as spondylosis.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

For applicable clinical criteria, see the following eviCore clinical guideline(s):

20936 20937 20938 20939 22533 22534 22558 22585 22612 22614 22630 22632 22633 22634 22800 22802 22804 22808 22810 22812 22842 22843 22844 22845 22846 22847 22853 22854 22859

Denial Statements

No additional statement.


Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.

Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.

Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites. 

Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.

Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. 

These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.


CPT® codes copyright American Medical Association® 2022. All rights reserved.

CDT codes copyright American Dental Association® 2022. All rights reserved.