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ACG
​
h.o.l.M.E.S.

Automated Clinical Guidelines

Spine2

Indicates Non-covered Service

Anterior Cervical Decompression with Fusion (ACDF) - Single Level (elective)
Anterior Cervical Decompression with Fusion (ACDF) - Multiple Level (elective)
Anterior Cervical Decompression with Fusion (ACDF) - Multiple Level (elective)
Anterior Vertebral Body  Tethering
Back Pain - Invasive Procedures
Cervical Decompression with or without Fusion
Cervical Fusion
Aetna
Aetna
Cigna
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Cervical Fusion (L39741, L39799, L39770, L39758, L39762, L39793, L39773, L39788)
Cervical Fusion for Treatment of Axial Neck Pain (elective)
Cervical Disc Replacement
Cervical Laminectomy for Herniated Disc
Cervical Laminoplasty
Cervical Posterior Decompression (elective)
Cervical Posterior Decompression with Fusion - Multiple Levels (urgent/

emergent)
Aetna
Anthem
Aetna
FloridaBlue
Cigna
Aetna
Humana
Point32Health
Medicare
UHC
Cervical Posterior Decompression with Fusion-Single Level (elective)
Referral Indications- Cervical Spine
Cervical Spine Procedures
Coccygectomy & Treatments for Coccydynia
Discography- Lumbar
Idiopathic Scoliosis Treatment
Anthem
Aetna
Growing Rods for Spinal Surgery
Aetna
FloridaBlue
Cigna
Humana
Interspinous Process Decompression
Intervertebral Disc Prostheses
Laminectomy, Laminotomy, Facetectomy, & Foraminotomy (elective)
Laminectomy and Fusion
Lumbar Laminectomy
Lumbar Discectomy/ Microdiscectomy (elective)
Lumbar Spinal Fusion
Medicare
Aetna
Anthem
Aetna
Anthem
Cigna
Anthem
Medicare
Humana
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Lumbar Fusion and Treatment of Spinal Deformity (including Scoliosis and Kyphosis)
Minimally Invasive Approaches to Vertebral Fractures & Osteolytic Lesions of the Spine
Referral Indications Lumbar Spine
Lumbar Spinal Procedures
Lumbar Total Disc Arthroplasty (TDA)
Multi-level Lumbar Fusions with or without decompression (elective)
Pedicle screws for spinal fixation and intervertebral body fusion devices
FloridaBlue
Anthem
FEP
Anthem
Medicare
UHC
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Percutaneous Vertebral Augmentation
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L33569, L34106, L34228, L38201, L34976, L35130, L38737, L38213)
Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis
(NCD 150.13)
Percutaneous Vertebral Disc and Vertebral Endplate Procedures
Recombinant Human Bone Morphogenetic Protein (BMP)
Repeat Lumbar Spine Fusion Operations (elective)
Anthem
FloridaBlue
Humana
Anthem
FloridaBlue
Sacral Nerve Stimulation
Minimally invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint (L36406)
Sacroiliac Joint Fusion
Sacroiliac Joint Procedures
Scoliosis and Spinal Deformity
Scoliosis Surgery (Vertebral Body Tethering)
Single Level Lumbar Fusion with or without decompression (elective)
Medicare
FloridaBlue
FloridaBlue
Anthem
Cigna
Medicare
Anthem
Spinal Decompression Surgery
Surgery for Spinal Deformity
Surgical Treatment of Chest Wall Deformities
Spinal Fusion
Thoracic laminectomy and/or thoracic diskectomy & fusion
Thoracic laminectomy and/or thoracic diskectomy & fusion
Thoracoscopic Sympathectomy
Humana
FloridaBlue
Cigna
Humana
Aetna
UHC
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