Ortho-spine

Spine

Indicates Non-covered Service

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

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

Cervical Disc Replacement

Back Pain - Invasive Procedures

Cervical Decompression with or without Fusion

Cervical Fusion for Treatment of Axial Neck Pain (elective)

Cervical laminectomy for herniated disc

Cervical Posterior Decompression (elective)

Cervical Posterior Decompression with Fusion - Multiple Levels (urgent/

Cervical Posterior Decompression with Fusion-Single Level (elective)

Referral Indications- Cervical Spine

Coccygectomy & Treatments for Coccydynia

Growing Rods for Spinal Surgery

Idiopathic Scoliosis Treatment

Interspinous Process Decompression

Intervertebral Disc Prostheses

Aetna

Laminectomy, Laminotomy, Facetectomy, & Foraminotomy (elective)

Laminectomy and Fusion

Lumbar Discectomy/ Microdiscectomy (elective)

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

Referral Indications Lumbar Spine

Lumbar Total Disc Arthroplasty (TDA)

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

Pedicle screws for spinal fixation and intervertebral body fusion devices

Percutaneous Vertebral Augmentation

Percutaneous Vertebral Disc and Vertebral Endplate Procedures

Recombinant Human Bone Morphogenetic Protein (BMP)

Repeat Lumbar Spine Fusion Operations (elective)

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

Scoliosis and Spinal Deformity

Single Level Lumbar Fusion with or without decompression (elective)

Humana

Surgical Treatment of Chest Wall Deformities

Spinal Fusion Surgery- All Levels

Thoracic laminectomy and/or thoracic diskectomy and fusion

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

FloridaBlue

Axial LIF

Aetna

Discography

UHC

Dynamic Spinal Stabilization Devices

Humana

Epidural Lysis of Adhesions

Humana

UHC

Epiduroscopy

UHC

FloridaBlue

Humana

Facet Arthroplasty

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

FloridaBlue

Cigna

Humana

Intradiscal Procedures

Aetna

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

FloridaBlue

Pulsed Radiofrequency

Aetna

Skeletal Analysis Systems

Aetna

Traction Devices – Cervical & Lumbar

Cigna

Aetna

UHC

Vertebral Axial Decompression

Aetna

Vertebral Body Tethering for Scoliosis

UHC

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

Anterior Vertebral Body Tethering

Scoliosis Surgery (Vertebral Body Tethering)

0200T, 0201T, 0202T, 0219T, 0220T, 0221T, 0222T, 0274T, 0275T, 20930, 20931, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22510, 22511, 22512, 22513, 22514, 22515, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22853, 22854, 22855, 22859, 22867, 22868, 22869, 22870, 22899, 27279, 27280, 62380, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63275, 63277, 63280, 63282, 63285, 63286, 63287, 63290, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63275, 63277, 63280, 63282, 63285, 63286, 63287, 63290, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, 63650, 63655, 63663, 63664, 63685, 63688, 64999, C1816, C1820, C1822, L8679, L8680, L8682, L8685, L8686, L8687, L8688