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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)
Cervical Disc Replacement
Back Pain - Invasive Procedures
Aetna
Cervical Decompression with or without Fusion
Aetna
Cervical Fusion
Cigna
Cervical Fusion for Treatment of Axial Neck Pain (elective)
Aetna
Anthem
Cigna
FloridaBlue
Humana
Medicare
UHC
Cervical Laminectomy for Herniated Disc
Cervical Laminoplasty
Aetna
Cervical Posterior Decompression (elective)
Aetna
Cervical Posterior Decompression with Fusion - Multiple Levels (urgent/

emergent)
Cervical Posterior Decompression with Fusion-Single Level (elective)
Anterior Cervical Decompression with Fusion (ACDF) - Multiple Level (elective)
Anterior Vertebral Body  Tethering
Point32Health
Referral Indications- Cervical Spine
Cervical Spine Procedures
FloridaBlue
Coccygectomy & Treatments for Coccydynia
Discography- Lumbar
Aetna
Cigna
Humana
Growing Rods for Spinal Surgery
Idiopathic Scoliosis Treatment
Aetna
Interspinous Process Decompression
Medicare
Intervertebral Disc Prostheses
Aetna
Anthem
Cigna
Humana
Laminectomy, Laminotomy, Facetectomy, & Foraminotomy (elective)
Laminectomy and Fusion
Lumbar Laminectomy
Aetna
Anthem
Lumbar Discectomy/ Microdiscectomy (elective)
Anthem
Medicare
Lumbar Spinal Fusion
Anthem
Lumbar Fusion and Treatment of Spinal Deformity (including Scoliosis and Kyphosis)
Referral Indications Lumbar Spine
Lumbar Spinal Procedures
FloridaBlue
Lumbar Total Disc Arthroplasty (TDA)
Anthem
Medicare
UHC
Multi-level Lumbar Fusions with or without decompression (elective)
Pedicle screws for spinal fixation and intervertebral body fusion devices
Anthem
Humana
FloridaBlue
Percutaneous Vertebral Disc and Vertebral Endplate Procedures
Anthem
Recombinant Human Bone Morphogenetic Protein (BMP)
FloridaBlue
Repeat Lumbar Spine Fusion Operations (elective)
Sacral Nerve Stimulation
FloridaBlue
Medicare
Minimally invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint (L36406)
Medicare
Sacroiliac Joint Fusion
Anthem
FloridaBlue
Sacroiliac Joint Procedures
Cigna
Scoliosis and Spinal Deformity
Single Level Lumbar Fusion with or without decompression (elective)
Spinal Decompression Surgery
Humana
Surgery for Spinal Deformity
FloridaBlue
Surgical Treatment of Chest Wall Deformities
Cigna
Spinal Fusion 
HumanaMA
Thoracic laminectomy and/or thoracic diskectomy & fusion
Thoracic laminectomy and/or thoracic diskectomy & fusion
UHC
Thoracoscopic Sympathectomy
Aetna
Scoliosis Surgery (Vertebral Body Tethering)
Anthem
Percutaneous Vertebral Augmentation
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