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02-61000-36

Original Effective Date: 03/15/10

Reviewed: 01/26/17

Revised: 02/15/17

Subject: Minimally Invasive Fusion Techniques

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
           
Other References Updates  

DESCRIPTION:

Spinal fusion is a technique of uniting two or more vertebrae together so there is no longer motion between them. Bone grafts are placed during surgery and may take several months to fuse together. Spinal fusion may be used to treat fractured vertebrae, abnormal curvature, pain caused by motion, treatment of spinal instability, or disc herniations.

A variety of minimally invasive (MI) procedures are being investigated to perform interbody fusion, with the intent of limiting iatrogenic damage to muscular, ligamentous, neural, and vascular structures. Minimally invasive techniques being studied include axial interbody fusion (AxiaLIF), interlaminar or intraspinous lumbar instrumented fusion (ILIF), transforaminal lumbar interbody fusion (TLIF) and lateral interbody fusion (e.g., extreme lateral interbody fusion [XLIF] or direct -lateral interbody fusion [DLIF]).

Axial Lumbar Interbody Fusion (AxiaLIF)

The procedure for 1-level axial lumbosacral interbody fusion (axial LIF) is as follows (1): Under fluoroscopic monitoring, a blunt guide pin introducer is passed through a 15- to 20-mm incision lateral to the coccyx and advanced along the midline of the anterior surface of the sacrum. A guide pin is introduced and tapped into the sacrum. A series of graduated dilators are advanced over the guide pin, and a dilator sheath attached to the last dilator is left in place to serve as a working channel for the passage of instruments. A cannulated drill is passed over the guide pin into the L5-S1 disc space to rest on the inferior endplate of L5. It is followed by cutters alternating with tissue extractors, and the nucleus pulposus is debulked under fluoroscopic guidance. Next, bone graft material is injected to fill the disc space. The threaded rod is placed over the guide pin and advanced through the sacrum into L5. The implant is designed to distract the vertebral bodies and restore disc and neural foramen height. Additional graft material is injected into the rod, where it enters into the disc space through holes in the axial rod. A rod plug is then inserted to fill the cannulation of the axial rod. Percutaneous placement of pedicle or facet screws may be used to provide supplemental fixation. An advantage of axial LIF is that it allows preservation of the annulus and all paraspinous soft tissue structures. However, there is an increased need for fluoroscopy and an inability to address intracanal pathology or visualize the discectomy procedure directly. Complications of the axial approach may include perforation of the bowel and injury to blood vessels and/or nerves.

Transforaminal Lumbar Interbody Fusion (TLIF)

TLIF is differentiated from the more traditional bilateral PLIF by a unilateral approach to the disc space through the intervertebral foramen. In minimally invasive TLIF, a single incision about 2-3 cm in length is made approximately 3 cm lateral to the midline. A tubular retractor is docked on the facet joint complex and a facetectomy with partial laminectomy is performed. Less dural retraction is needed with access through the foramen via unilateral facetectomy, and contralateral scar formation is eliminated. TLIF provides access to the posterior elements along with the intervertebral disc space.

Lateral Interbody Fusion (e.g., extreme lateral interbody fusion [XLIF] or direct lateral interbody fusion [DLIF])

Lateral Interbody Fusion (e.g., extreme lateral interbody fusion [XLIF] or direct lateral interbody fusion [DLIF]) uses specialized retractors in a MI, lateral approach to the anterior spine through the psoas. In comparison with ALIF, the lateral approach does not risk injury to the peritoneum or great vessels. However, exposure to the spine may be more limited, and dissection of the psoas major places the nerves of the lumbar plexus at risk. Electromyographic monitoring and dissection predominantly within the anterior psoas major may be utilized to reduce the risk of nerve root injury. These various factors decrease the ability to perform a complete discectomy and address pathology of the posterior elements.

Sacroiliac fusion involves bony fusion of the sacroiliac joint for stabilization. This has been proposed for treatment of chronic sacroiliac pain. Several percutaneous or minimally invasive fixation/fusion devices have received marketing clearance by the FDA. These include the SI-FIX Sacroiliac Joint Fusion System, the IFUSE® Implant System, the SImmetry® Sacroiliac Joint Fusion System, the Silex™ and the SI-LOK®.

Surgical devices for annular repair or modulation after spinal surgery, according to FDA documentation, are intended for use in soft tissue approximation, or repair of annular defect, for procedures such as general and orthopedic surgery. There are several FDA-approved, commercially marketed devices.

POSITION STATEMENT:

Minimally invasive interbody fusion of the lumbar spine may be considered medically necessary using the following approaches:

Axial lumbosacral interbody fusion (Axial LIF) is considered experimental or investigational for all indications. There is insufficient scientific evidence to permit conclusions concerning the effect of this technology on net health outcomes.

Open sacroiliac joint fusion/stabilization (27280) meets the definition of medical necessity for any of the following indications:

• A tumor involving the sacrum and/or sacroiliac joint

• As adjunctive treatment of sacroiliac joint infection, following successful treatment of the infection

• Following traumatic injury of the sacroiliac joint (e.g., following pelvic ring fracture)

• When performed as a part of multi-segment long fusion to correct spinal deformity associated with scoliosis or kyphosis

Sacroiliac joint fusion/stabilization for the treatment of chronic back pain, including open, percutaneous and minimally invasive techniques, is considered experimental or investigational. The available scientific evidence remains insufficient to permit conclusions concerning the effect of this technology on net health outcomes.

The use of surgical devices for annular repair/modulation following spinal surgery (e.g. Inclose Surgical Mesh System, Xclose™ Tissue Repair System, DiscFX™ System, Disc Annular Repair Technology (DART) System, Barricaid) is considered experimental or investigational due to the lack of scientific peer-reviewed literature demonstrating improvement in health outcomes.

BILLING/CODING INFORMATION:

The following codes may be used to pre-sacral interbody fusion.

CPT Coding:

22586

Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace (investigational)

27279

Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (investigational)

27280

Arthrodesis, open, sacroiliac joint, including obtaining graft, including instrumentation, when performed

0195T

Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L5-S1 interspace (investigational)

0196T

Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L4-L5 interspace (List separately in addition to code for primary procedure) (investigational)

0309T

Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (List separately in addition to code for primary procedure) (investigational)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage: The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Noncovered Services (L33777) located at fcso.com. The following coverage article was reviewed on the last guideline reviewed date: Local Coverage Article: Medical review article for percutaneous minimally invasive fusion/stabilization of the SACROILIAC JOINT (A55120) located at cms.gov.

DEFINITIONS:

Anulus fibrosus: The ring of fibrocartilage and fibrous tissue forming the circumference of the intervertebral disc; surrounds the nucleus pulpous, which can herniate when the anulus is diseased or injured.

Interbody: Between the bodies of two adjacent vertebra.

Interspace: Any space between two similar objects.

RELATED GUIDELINES:

Bone Morphogenetic Protein (BMP), 02-20000-32
Interspinous and Interlaminar Stabilization/Distraction (Spacers) and Fixation (Fusion) Devices, 02-20000-36

Percutaneous Decompression of Intervertebral Discs, 02-61000-32

OTHER:

None applicable

REFERENCES:

  1. Ackerman SJ, Polly Jr DW, Knight T, Schneider K, Holt T, Cummings J. Comparison of the costs of nonoperative care to minimally invasive surgery for sacroiliac joint disruption and degenerative sacroiliitis in a United States Medicare population: potential economic implications of a new minimally-invasive technology. ClinicoEconomics and outcomes research: CEOR (2013), 5, 575.
  2. AHRQ national Guideline Clearinghouse. Guideline Summary NGC-8134. Laminectomy and fusion for the treatment of cervical degenerative myelopathy. American Association of Neurological Surgeons; Congress of Neurological Surgeons. 2009 Aug.
  3. AHRQ national Guideline Clearinghouse. Guideline Summary NGC-8766. Diagnosis and treatment of degenerative lumbar spinal stenosis. North American Spine Society (NASS); 2011.
  4. AHRQ national Guideline Clearinghouse. Guideline Summary NGC-9903. Clinical guidelines for diagnosis and treatment of lumbar disc herniation with radiculopathy. North American Spine Society; 2012.
  5. AHRQ national Guideline Clearinghouse. Guideline Summary NGC-9327. Low back disorders. American College of Occupational and Environmental Medicine (ACOEM); 2011.
  6. AHRQ national Guideline Clearinghouse. Guideline Summary NGC-10118: Hip & pelvis (acute & chronic). Work Loss Data Institute; 2013.
  7. AHRQ national Guideline Clearinghouse. Guideline Summary NGC-10121. Low back - lumbar & thoracic (acute & chronic). Work Loss Data Institute; 2013.
  8. American Academy of Orthopaedic Surgeons. Anterior Lumbar Interbody Fusion. Accessed at http://orthoinfo.aaos.org/topic.cfm?topic=A00595. Copyright 2010 American Academy of Orthopaedic Surgeons.
  9. American Academy of Orthopaedic Surgeons. Posterior Lumbar Interbody Fusion and Transforaminal Lumbar Interbody Fusion. Accessed at http://orthoinfo.aaos.org/topic.cfm?topic=A00596. Copyright 2010 American Academy of Orthopaedic Surgeons.
  10. Aryan HE, Newman CB, Gold JJ, Acosta Jr. FL, Coover C, Ames CP. Percutaneous Axial Lumbar Interbody Fusion (AxiaLIF) of the L5-S1 Segment: Initial Clinical and Radiographic Experience. Minim Invas Neurosurg 2008; 51: 225 – 230.
  11. Ashman B, Norvell DC, Hermsmeyer JT. Chronic sacroiliac joint pain: fusion versus denervation as treatment options. Evidence-Based Spine-Care JournalVolume 1/Issue 3 — 2010.
  12. Bahtia NN, Timon S, Wieser ES, Wang JC. TLIF, XLIF or ALIF for adjacent segment degenerative disc disease. NASS SpineLine, May/June 2008.
  13. Bailey A, Messer J, Griffith SL. (2010). Prospective, Randomized Controlled Study of Repairing the Anulus Fibrosus after Lumbar Discectomy: A Single Surgeon's Experience. The Spine Journal, 10(9), S127.
  14. Blue Cross Blue Shield Association. Medical Policy Reference Manual. 6.01.23 Diagnosis and Treatment of Sacroiliac Joint Pain. October 2016.
  15. Blue Cross Blue Shield Association. Medical Policy Reference Manual. 7.01.115 Percutaneous Axial Anterior Lumbar Fusion. (Archived 11/10/11).
  16. Blue Cross Blue Shield Association. Medical Policy Reference Manual. 7.01.130 Axial Lumbosacral Interbody Fusion. November 2014.
  17. Blumenthal, SL, Guyer RD. (2010, October). Anular Repair After Lumbar Discectomy: Preliminary Observations From An Ongoing, Prospective, Randomized, Controlled Clinical Trial: 41. In Spine Journal Meeting Abstracts (p. 41).
  18. Boachie-Adjei O, Cho W, King AB. Axial lumbar interbody fusion (AxiaLIF) approach for adult scoliosis. Eur Spine J. 2013 Mar;22 Suppl 2:S225-31.
  19. Capobianco R, et al. Safety and effectiveness of minimally invasive sacroiliac joint fusion in women with persistent post-partum posterior pelvic girdle pain: 12-month outcomes from a prospective, multi-center trial. Springerplus. 2015 Oct 5;4:570.
  20. Caputo AM, Michael KW, Chapman Jr TM, Massey GM, Howes CR, Isaacs RE, Brown CR. Clinical outcomes of extreme lateral interbody fusion in the treatment of adult degenerative scoliosis. ScientificWorldJournal. 2012;2012:680643.
  21. Cher DJ, Polly DW. Improvement in Health State Utility after Sacroiliac Joint Fusion: Comparison to Normal Populations. Global Spine Journal. 2016 Mar;6(2):100.
  22. Cher DJ, Reckling WC, Capobianco RA. Implant survivorship analysis after minimally invasive sacroiliac joint fusion using the iFuse Implant System (®). Medical devices (Auckland, NZ). 2015 Nov 23;8:485.
  23. Cho CB, et al, Anterior Lumbar Interbody Fusion with Stand-Alone Interbody Cage in Treatment of Lumbar Intervertebral Foraminal Stenosis: Comparative Study of Two Different Types of Cages, J Korean Neurosurg Soc, 47: 352-357, 2010.
  24. Choy W-S, Kim KJ, Lee SK, Park HJ. Anterior Pelvic Plating and Sacroiliac Joint Fixation in Unstable Pelvic Ring Injuries. Yonsei Med J 53(2):422-426, 2012.
  25. ClinicalTrials.gov, A Clinical Study of the GO-LIF® Approach for Lumbar Spinal Fixation. NCT00810433. Sponsored by Mazor Surgical Technologies, Ltd, last updated: February 6, 2011. Accessed 12/28/10.
  26. ClinicalTrials.gov. Osteocel® Plus in eXtreme Lateral Interbody Fusion (XLIF®), NCT00948532. Sponsored by NuVasive, last updated June 10, 2011. Accessed 01/02/13.
  27. ClinicalTrials.gov. XLIF® vs. MAS®TLIF for the Treatment of Symptomatic Lumbar Degenerative Spondylolisthesis With or Without Central Stenosis. NCT01024699. Sponsored by NuVasive, accessed 01/06/12. last updated on June 10, 2011. Accessed 01/06/12.
  28. ClinicalTrials.gov. Randomized Study of Anular Repair with the Xclose Tissue Repair System. NCT00760799. Sponsored by Anulex Technologies, Inc, last updated: May 1, 2012. Accessed 12/28/10.
  29. ClinicalTrials.gov. NCT00965380. Trinity Evolution in Posterior or Transforaminal Lumbar Interbody Fusion (PLIF/TLIF) (TLF), Sponsored by Orthofix Inc., last updated on May 22, 2012. Accessed 01/16/12.
  30. ClinicalTrials.gov. Osteocel® Plus in Anterior Lumbar Interbody Fusion (ALIF). NCT00948831. NuVasive, last updated June 10, 2011. Accessed 01/02/13.
  31. ClinicalTrials.gov. NCT01640353: Sacroiliac Joint Fusion With iFuse Implant System (SIFI). August 2014.
  32. ClinicalTrials.gov. NCT01681004: Investigation of Sacroiliac Fusion Treatment (INSITE). September 2014.
  33. ClinicalTrials.gov. NCT01741025: iFuse Implant System® Minimally Invasive Arthrodesis (iMIA). January 2014.
  34. ClinicalTrials.gov. NCT01861899: Treatment of Sacroiliac Dysfunction With SI-LOK® Sacroiliac Joint Fixation SI-SI-LOK. May 2013.
  35. ClinicalTrials.gov. NCT02074761: Evolusion Study Using the Zyga SImmetry Sacroiliac Joint Fusion System. July 2015.
  36. ClinicalTrials.gov. NCT02064322: SAIF: Sacroiliac Fusion Study. April 2015.
  37. ClinicalTrials.gov. NCT02270203: LOIS: Long-Term Follow-Up in INSITE/SIFI (LOIS) (SI-Bone, Inc.) (August 2016).
  38. Cummings Jr J, Capobianco RA. Minimally invasive sacroiliac joint fusion: one-year outcomes in 18 patients. Ann Surg Innov Res. 2013 Sep 16;7(1):12.
  39. DeVine JG, Gloystein D, Singh N. A novel alternative for removal of the AxiaLif (TranS1) in the setting of pseudarthrosis of L5–S1. The Spine Journal 9 (2009) 910–915.
  40. Duhon BS, Cher DJ, Wine KD, Lockstadt H, Kovalsky D, Soo CL. Safety and 6-month effectiveness of minimally invasive sacroiliac joint fusion: a prospective study. Med Devices (Auckl). 2013 Dec 13;6:219-29.
  41. Duhon BS, et al. Triangular Titanium Implants for Minimally Invasive Sacroiliac Joint Fusion: A Prospective Study. Global Spine Journal. June 30, 2015.
  42. Duhon BS, et al. Triangular Titanium Implants for Minimally Invasive Sacroiliac Joint Fusion: 2-Year Follow-Up from a Prospective Multicenter Trial. Int J Spine Surg. 2016 Apr 20;10:13.
  43. Duhon BS, et al. Triangular Titanium Implants for Minimally Invasive Sacroiliac Joint Fusion: A Prospective Study. Global spine journal. 2016 May;6(3):257-69.
  44. Eck JC, Hodges S, Humphreys SC. Minimally invasive lumbar spinal fusion. J Am Acad Orthop Surg. 2007; 15(6):321-329.
  45. ECRI Institute Health Technology Information Service: Product Brief. iFuse Implant System (SI-Bone, Inc.) for Minimally Invasive Sacroiliac Joint Fusion (May 2016).
  46. Endres S, Ludwig E. Outcome of distraction interference arthrodesis of the sacroiliac joint for sacroiliac arthritis. Indian journal of orthopaedics (2013), 47(5), 437.
  47. Erkan S, et al, Biomechanical Evaluation of a New AxiaLIF Technique for Two-Level Lumbar Fusion, Eur Spine J (2009), 18:807-814.
  48. Florida Medicare Part B Local Coverage Determination. Non-covered Services (L29288). 02/02/09. Retired 09/30/15.
  49. First Coast Service Options, Inc. (FCSO). Local Coverage Article: Medical review article for percutaneous minimally invasive fusion/stabilization of the SACROILIAC JOINT (A55120). Accessed at cms.gov.
  50. First Coast Service Options, Inc. (FCSO). Local Coverage Determination (LCD) L33777: Noncovered Services. 10/01/15.
  51. Garber T, Ledonio CG, Polly Jr DW. How Much Work Effort is Involved in Minimally Invasive Sacroiliac Joint Fusion?. International journal of spine surgery. 2015 Nov 6;9:58.
  52. Griffith SL, Davis RJ, Hutton WC. Repair of the anulus fibrosus of the lumbar disc. In: Davis RJ, Girardi FP, Cammisa FP editor. Nucleus arthoplasty technology in spinal care, volume II: biomechanics and development. Bloomington, MN: Raymedica Inc; 2007;p. 41–48.
  53. Gundanna MI, Miller LE, Block JE. Complications with axial presacral lumbar interbody fusion: A 5-year postmarketing surveillance experience. SAS Journal 5 (2011) 90–94.
  54. Ha KY, Lee JS, Kim KW. Degeneration of sacroiliac joint after instrumented lumbar or lumbosacral fusion: a prospective cohort study over five-year follow-up. Spine (Phila Pa 1976). 2008 May 15;33(11):1192-8.
  55. Habib A, Smith ZA, Lawton CD, Fessler RG. Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Perspective on Current Evidence and Clinical Knowledge. Minimally Invasive Surgery Volume 2012, Article ID 657342.
  56. Hadjipavlou A, Alpantaki K, Katonis P, Vastardis G, Tzermiadianos M, Benardos N. Safety and effectiveness of retrorectal presacral approach for lumbosacral axial instrumentation. A clinical study. Acta Orthop Belg. 2013 Apr;79(2):222-9.
  57. Heiney J, Capobianco R, Cher D. A systematic review of minimally invasive sacroiliac joint fusion utilizing a lateral transarticular technique. Int J Spine Surg. 2015 Jul 22;9:40.
  58. Inamasu J, Guiot BH. Laparoscopic Anterior Lumbar Interbody Fusion: A Review of Outcome Studies. Minim Invas Neurosurg 2005; 48: 340±347.
  59. International Society for the Advancement of Spine Surgery (ISASS). Proposed Recommendations for “Coverage Criteria”: Minimally Invasive Sacroiliac Joint Fusion. March 2014. Accessed at http://www.isass.org/.
  60. International Society for the Advancement of Spine Surgery. Statement on Coding Changes for Minimally Invasive SI Joint Fusion July 2013). Accessed at www.isass.org.
  61. InterQual® 2013.2. CP Procedures: Fusion, Lumbar Spine.
  62. Ledonio CGT, Polly DW, Swiontkowski MF, Cummings Jr JT. Comparative effectiveness of open versus minimally invasive sacroiliac joint fusion. Medical Devices: Evidence and Research 2014:7 187–193.
  63. Ledonio CG, Polly DW Jr, Swiontkowski MF. Minimally invasive versus open sacroiliac joint fusion: are they similarly safe and effective? Clin Orthop Relat Res. 2014 Jun;472(6):1831-8.
  64. Lee KH, Yue WM, Yeo W, Soeharno H, Tan SB. Clinical and radiological outcomes of open versus minimally invasive transforaminal lumbar interbody fusion. Eur Spine J. 2012 Nov;21(11):2265-70.
  65. Lindley EM, McCullough MA, Burger EL, Brown CW, Patel VV. Complications of axial lumbar interbody fusion. J Neurosurg Spine 15:273–279, 2011.
  66. Lindsey DP, et al. Evaluation of a minimally invasive procedure for sacroiliac joint fusion – an in vitro biomechanical analysis of initial and cycled properties. Medical Devices: Evidence and Research 2014:7 131–137.
  67. Lindsey DP, Kiapour A, Yerby SA, Goel VK. Sacroiliac Joint Fusion Minimally Affects Adjacent Lumbar Segment Motion: A Finite Element Study. International journal of spine surgery. 2015 Nov 13;9:64.
  68. Lorio MP. ISASS Policy 2016 Update - Minimally Invasive Sacroiliac Joint Fusion. Int J Spine Surg. 2016 Jul 13;10:26.
  69. Lorio MP, Polly Jr DW, Ninkovic I, Ledonio CGT, Hallas K, Andersson G. Utilization of Minimally Invasive Surgical Approach for Sacroiliac Joint Fusion in Surgeon Population of ISASS and SMISS Membership. The Open Orthopaedics Journal, 2014, 8, 1-6.
  70. Lorio MP , Rashbaum R. ISASS Policy Statement – Minimally Invasive Sacroiliac Joint Fusion. International Journal of Spine Surgery Volume 8 Article 25.
  71. Malham GM, Ellis NJ, Parker RM, Seex KA. Clinical outcome and fusion rates after the first 30 extreme lateral interbody fusions. ScientificWorldJournal. 2012;2012:246989.
  72. Manchikanti L, et al. An Update of Comprehensive Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain. Part II: Guidance and Recommendations. Pain Physician 2013; 16:S49-S283 • ISSN 1533-3159.
  73. Marchi L, Abdala N, Oliveira L, Amaral R, Coutinho E, Pimenta L. Stand-Alone Lateral Interbody Fusion for the Treatment of Low-Grade Degenerative Spondylolisthesis. ScientificWorldJournal. 2012; 2012:456346.
  74. Marotta N, Cosar M, Pimenta L, et al. A novel minimally invasive presacral approach and instrumentation technique for anterior L5 – S1 intervertebral discectomy and fusion: technical description and case presentations. Neurosurg Focus. 2006 Jan 15; 20(1):E9.
  75. Miller LE, Block JE. Minimally invasive arthrodesis for chronic sacroiliac joint dysfunction using the SImmetry SI Joint Fusion system. Medical Devices: Evidence and Research 2014:7 125–130.
  76. Miller LE, Reckling WC, Block JE. Analysis of postmarket complaints database for the iFuse SI Joint Fusion System®: a minimally invasive treatment for degenerative sacroiliitis and sacroiliac joint disruption. Med Devices (Auckl). 2013 May 29;6:77-84.
  77. Nandyala SV, Fineberg SJ, Pelton M, Singh K. Minimally invasive transforaminal lumbar interbody fusion: one surgeon's learning curve. Spine J. 2013 Oct 3. pii: S1529-9430(13)01493-9.
  78. National Institute for Health and Clinical Excellence (NICE), Lateral (Including Extreme, Extra and Direct Lateral) Interbody Fusion in the Lumbar Spine- Interventional Procedure Guidance 321, Issue Date: November 2009, accessed at guidance.nice.org.uk 01/28/14.
  79. National Institute for Health and Clinical Excellence (NICE). Intervention Procedure Guidance 387, Transaxial interbody lumbosacral fusion. Issue date: March 2011. Accessed at nice.org.uk/ 01/28/14.
  80. National Institute for Health and Clinical Excellence (NICE), Transaxial Interbody Lumbosacral Fusion- consultation Document, London UK: NICE; December 2010.
  81. NeurosurgeryToday.org. Minimally Invasive Spine Surgery (MIS). January 2009.
  82. North American Spine Society. Percutaneous Sacroiliac Joint Fusion: Defining Appropriate Coverage Positions. May 31, 2015.
  83. North American Spine Society (NASS). Public Education Series. Spinal Fusion. 2006 – 2009 North American Spine Society. Accessed 01/09/12.
  84. Official Disability Guidelines (ODG). Medical Treatment and Return to Work Guidelines. Evidence-Based Decision Support: Percutaneous Sacroiliac Joint Fusion.
  85. Ozgur BM, Aryan HE, Pimenta L, Taylor WR. Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar Interbody fusion. Spine J. 2006 July – August; 6(4): 435-43.
  86. Park P, Foley KT. Minimally invasive transforaminal lumbar interbody fusion with reduction of spondylolisthesis: technique and outcomes after a minimum of 2 years’ follow-up. Neurosurg Focus 25 (2):E16, 2008.
  87. Patil SS, Lindley EM, et al, Clinical and Radiological Outcomes of Axial Lumbar Interbody Fusion, Spine Center, Department of Orthopedics, University of Colorado Denver, Colorado, accessed at orthosupersite.com 01/05/11.
  88. Polly DW, et al. Does Level of Response to SI Joint Block Predict Response to SI Joint Fusion? Int J Spine Surg. 2016 Jan 21;10:4.
  89. Polly DW, et al. Neurosurgery. 2015 Nov;77(5):674-90; discussion 690-1. Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion Using Triangular Titanium Implants vs Nonsurgical Management for Sacroiliac Joint Dysfunction: 12-Month Outcomes.
  90. Polly DW, et al. Two-Year Outcomes from a Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion vs. Non-Surgical Management for Sacroiliac Joint Dysfunction. Int J Spine Surg. 2016 Aug 23;10:28.
  91. Rapp SM, Miller LE, Block JE. AxiaLIF system: minimally invasive device for presacral lumbar interbody spinal fusion. Med Devices (Auckl). 2011;4:125-31.
  92. Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 11: interbody techniques for lumbar fusion. J Neurosurg Spine. 2005 June;2(6):692-9.
  93. Rudolf L. MIS Fusion of the SI Joint: Does Prior Lumbar Spinal Fusion Affect Patient Outcomes? The open orthopaedics journal (2013), 7, 163.
  94. Rudolf L. Sacroiliac joint arthrodesis-MIS technique with titanium implants: report of the first 50 patients and outcomes. The open orthopaedics journal (2012), 6, 495.
  95. Rudolph L, Capobianco R. Five-Year Clinical and Radiographic Outcomes After Minimally Invasive Sacroiliac Joint Fusion Using Triangular Implants. The Open Orthopaedics Journal, 2014, 8, 375-383.
  96. Saavoss JD, Koenig L, Cher DJ. Productivity benefits of minimally invasive surgery in patients with chronic sacroiliac joint dysfunction. ClinicoEconomics and outcomes research: CEOR. 2016 Apr 11;8:77.
  97. Sachs D, Capobianco R. One year successful outcomes for novel sacroiliac joint arthrodesis system. Ann Surg Innov Res. 2012 Dec 27;6(1):13.
  98. Sachs D, Capobianco R. Minimally invasive sacroiliac joint fusion: one-year outcomes in 40 patients. Advances in orthopedics, 2013.
  99. Sachs D, et al. One-year outcomes after minimally invasive sacroiliac joint fusion with a series of triangular implants: a multicenter, patient-level analysis. Medical Devices: Evidence and Research 2014:7 299–304.
  100. Sachs D, et al. Durable intermediate-to long-term outcomes after minimally invasive transiliac sacroiliac joint fusion using triangular titanium implants. Med Devices (Auckl). 2016 Jul 13;9:213-22.
  101. Schroeder JE, Cunningham ME, Ross T, Boachie-Adjei O. Early Results of Sacro–Iliac Joint Fixation Following Long Fusion to the Sacrum in Adult Spine Deformity. HSS Journal® (2014) 10(1), 30-35.
  102. Shaffrey CI, Smith JS. Editorial: Stabilization of the sacroiliac joint. Neurosurg Focus (Suppl) 35:Editorial, 2013.
  103. Sharma AK, Kepler CK, Girardi FP, Cammisa FP, Huang RC, Sama AA. Lateral lumbar interbody fusion: clinical and radiographic outcomes at 1 year: a preliminary report. J Spinal Disord Tech. 2011 Jun;24(4):242-
  104. Shen FH, Samartzis D, Khanna AJ, et al. Minimally invasive techniques for lumbar interbody fusions. Orthop Clin North Am. 2007 Jul; 38(3):373-86.
  105. Smith AG, Capobianco R, Cher D, Rudolf L, Sachs D, Gundanna M, Shamie AN. Open versus minimally invasive sacroiliac joint fusion: a multi-center comparison of perioperative measures and clinical outcomes. Ann Surg Innov Res. 2013 Oct 30;7(1):14. doi: 10.1186/1750-1164-7-14.
  106. Society for Minimally Invasive Spine Surgery. Position Statement on Presacral Lumbar Interbody Fusion (February 29, 2012). Accessed at www.smiss.org.
  107. Spain K, et al. Surgical Revision after Sacroiliac Joint Fixation or Fusion. Minimally Invasive Surgery Volume 11 Issue 1 pp 24 – 30.
  108. Stark, John G., J. Abner Fuentes, Tania I. Fuentes, and Christopher Idemmili. The history of sacroiliac joint arthrodesis: a critical review and introduction of a new technique. Current Orthopaedic Practice 22, no. 6 (2011): 545-557.
  109. Stippler M, Turka M, & Gerszten P. C. Outcomes after Percutaneous TranS1 AxiaLIF® L5 – S1 Interbody Fusion for Intractable Lower Back Pain. The Internet Journal of Spine Surgery. 2009 Volume 5, Number 1.
  110. Stuber KJ. Specificity, sensitivity, and predictive values of clinical tests of the sacroiliac joint: a systematic review of the literature. J Can Chiropr Assoc. 2007 Mar;51(1):30-41.
  111. Sturesson B, et al. Six-month outcomes from a randomized controlled trial of minimally invasive SI joint fusion with triangular titanium implants vs conservative management. Eur Spine J. 2016 May 14.
  112. Szadek KM, van der Wurff P, van Tulder MW, Zuurmond WW, Perez RS. Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. J Pain. 2009 Apr;10(4):354-68.
  113. Tang S. Does TLIF Aggravate Adjacent Segmental Degeneration More Adversely than ALIF? A Finite Element Study. Turkish Neurosurgery 2012, Vol: 22, No: 3, 324-328.
  114. Tobler WD, Ferrara LA. The presacral retroperitoneal approach for axial lumbar interbody fusion: A prospective study of clinical outcomes, complications and fusion rates at a follow-up of two years in 26 patients. J Bone Joint Surg [Br] 2011; 93-B:955-60.
  115. Tobler WD, Melgar MA, Raley TJ, Anand N, Miller LE, Nasca RJ. Clinical and radiographic outcomes with L4-S1 axial lumbar interbody fusion (AxiaLIF) and posterior instrumentation: a multicenter study. Medical Devices (Auckland, NZ) (2013), 6, 155.
  116. Tobler WD, Gerszten PC, Bradley WD, Raley TJ, Nasca RJ, Block JE. Clinical Case Series: Minimally Invasive Axial Presacral L5–S1 Interbody Fusion. Two-Year Clinical and Radiographic Outcomes. SPINE Volume 36, Number 20, pp 1–6, September 2011.
  117. Tohmeh AG, Watson B, Tohmeh M, Zielinski XJ.Allograft cellular bone matrix in extreme lateral interbody fusion: preliminary radiographic and clinical outcomes. ScientificWorldJournal. 2012;2012:263637.
  118. Tsahtsarlis A, Wood M. Minimally invasive transforaminal lumber interbody fusion and degenerative lumbar spine disease. Eur Spine J. 2012 Nov;21(11):2300-5.
  119. Vanaclocha VV, Verdú-López F, Sánchez-Pardo M, Gozalbes-Esterelles L, Herrera JM. (2014). Minimally Invasive Sacroiliac Joint Arthrodesis: Experience in a Prospective Series with 24 Patients. J Spine, 3(185), 2.
  120. Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J. 2008 Jun;17(6):794-819.
  121. Wang X, Xu J, Zhu Y, Li J, Zhou S, Tian S, Xiang Y, Liu X, Zheng Y, Pan T. Biomechanical analysis of a newly developed shape memory alloy hook in a transforaminal lumbar interbody fusion (TLIF) in vitro model. PLoS One. 2014 Dec 4;9(12):e114326.
  122. Whang P, et al. Sacroiliac Joint Fusion Using Triangular Titanium Implants vs. Non-Surgical Management: Six-Month Outcomes from a Prospective Randomized Controlled Trial. Int J Spine Surg. 2015 Mar 5;9:6.
  123. Whang PG, Sasso RC, Patel VV, Ali RM, Fischgrund JS. Comparison of axial and anterior interbody fusions of the L5-S1 segment: a retrospective cohort analysis. J Spinal Disord Tech. 2013 Dec;26(8):437-43.
  124. Wong CK, Johnson EK. A narrative review of evidence-based recommendations for the physical examination of the lumbar spine, sacroiliac and hip joint complex. Musculoskelet. Care 10 (2012) 149–161.
  125. Wu WJ, Liang Y, Zhang XK, Cao P, Zheng T. Complications and clinical outcomes of minimally invasive transforaminal lumbar interbody fusion for the treatment of one- or two-level degenerative disc diseases of the lumbar spine in patients older than 65 years. Chinese Medical Journal 2012;125(14):2505-2510.
  126. Zeilstra DJ, Miller LE, Block JE. Axial lumbar interbody fusion: a 6-year single-center experience. Clinical interventions in aging (2013), 8, 1063.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 01/26/17.

GUIDELINE UPDATE INFORMATION:

03/15/10

New Medical Coverage Guideline.

02/15/11

Annual review; position statement maintained and references updated.

01/26/12

Scheduled review. Position statement maintained; updated description section and references.

01/01/13

Annual CPT coding update. Added 22586 and 0309T. Revised code descriptors for 0195T and 0196T.

02/15/13

Scheduled review. Position statement maintained. Revised description and updated references.

03/15/14

Scheduled review. Revised description, position statement, program exceptions and CPT coding. Updated references.

12/15/14

Unscheduled review. Revised position statement (coverage for open SI joint fusion). Updated references.

01/01/15

Annual CPT/HCPCS update. Added 27279. Revised 27280 descriptor. Deleted 0334T.

03/15/15

Scheduled review. Position statement maintained. Updated references. Reformatted guideline.

03/15/16

Scheduled review. Position statement maintained. Updated references.

02/15/17

Scheduled review. Position statement maintained. Updated references.

Date Printed: October 20, 2017: 02:06 PM