Description
General Information

• It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.
• The guideline criteria in the following sections were developed utilizing evidence-based and peer-reviewed resources from medical publications and societal organization guidelines as well as from widely accepted standard of care, best practice recommendations.

Purpose
This guideline covers the surgical indications for adult spinal deformity. Whenever possible, spinal deformity in adults is treated non-operatively.

Scope
Spinal surgeries should be performed only by those with extensive surgical training (neurosurgery, orthopedic surgery). Choice of surgical approach is based on anatomy, pathology, and the surgeon's experience and preference.

Instrumentation, bone formation or grafting materials, including biologics, should be used at the surgeon’s discretion; however, use should be limited to FDA approved indications regarding the specific devices or biologics.

All surgery requests to treat adult deformity will be reviewed on a case-by-case basis. Operative treatment is indicated when the natural history of surgically treated lesions is better than the natural history for non-operatively treated lesions. All operative interventions must be based on a positive correlation with clinical findings, the natural history of the disease, the clinical course, and diagnostic tests or imaging results. All individuals being considered for surgical intervention should receive a comprehensive neuromusculoskeletal examination to identify pain generators that may either respond to non-surgical techniques or may be refractory to surgical intervention.

Special Note
In order for surgeries to be considered medically necessary there must be clear medical records that demonstrate a clear surgical plan that matches the request for surgery.
 

Policy

INDICATIONS
Thoracic Deformity (Minimal/Secondary/Flexible Lumbar Involvement) in Adults

• When ALL the following criteria are met ^(1-3):
  • Individual has significant pain or symptoms that impairs daily activities for ≥ 6 months
  • Failure of symptom or pain improvement upon completion of at least 12 weeks of focused non-operative therapy/rehabilitation* in the past year
  • Imaging studies confirm spinal curvature and demonstrate at least one of the following:
    • Spinal curvature > 75 degrees (kyphosis); 
    • Severe kyphosis (chin-brow vertical angle greater than 35 degrees).

Lumbar Deformity (With or Without Secondary Thoracic Involvement) in Adults

• When ALL the following criteria are met ^(1-3):
  • Lumbar back pain, neurogenic claudication, and/or radicular leg pain without significant motor deficit (0-3/5) that impairs daily activities for at least 6 months
  • Failure of symptom or pain improvement upon completion of at least 12 weeks of focused non-operative therapy/rehabilitation* in the past year
  • Imaging studies that correspond to clinical findings and show at least one of the following:
    • Sagittal or coronal imbalance of at least 5 cm measured on long plate standing x-rays of the entire spine
    • A fixed scoliosis of at least 40 degrees

*Non-Operative Care ^(2,4,5)

• Documented failure of at least twelve (12) consecutive weeks in the past year of any TWO of the following physician-directed conservative treatments:
  • Analgesics, steroids, and/or NSAIDs
  • Structured program of physical therapy aimed at increasing core muscle strength
  • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician
  • Epidural steroid injections and or facet injections/selective nerve root block

Relative Contraindications for Spine Surgery^(6-8)
NOTE: Cases may not be approved if the below contraindications exist:

• Medical contraindications to surgery. (e.g., osteoporosis; infection of soft tissue adjacent to the spine, whether or not it has spread to the spine; severe cardiopulmonary disease; anemia; malnutrition, systemic infection, and elevated blood sugar) ⁽⁹⁾
• Psychosocial risk factors. It is imperative to rule out non-physiologic modifiers of pain presentation or non-operative conditions mimicking radiculopathy or instability (e.g., peripheral neuropathy, piriformis syndrome, myofascial pain, sympathetically mediated pain syndromes, sacroiliac dysfunction, psychological conditions, etc.) prior to consideration of elective surgical intervention. ^(9,10) Individuals with clinically significant depression or other psychiatric disorders being considered for elective spine surgery will be reviewed on a case-by-case basis and the surgery may be denied for risk of failure.
• Active Tobacco or Nicotine use prior to fusion surgery: Individuals must be free from smoking and/or nicotine use for at least six weeks prior to surgery and during the entire period of fusion healing. Cessation must be confirmed by a negative cotinine test prior to surgery approval. ^(11,12)
• Morbid Obesity: Contraindication to surgery in cases where there is significant risk and concern for improper post-operative healing, post-operative complications related to morbid obesity, and/or an inability to participate in post-operative rehabilitation. ^(13,14) These cases will be reviewed on a case-by-case basis and may be denied given the risk of failure.

SUMMARY OF EVIDENCE
Preoperative medical assessment for adult spinal deformity surgery: a state‑of‑the‑art review ⁽⁶⁾

Study Design: This study is a state-of-the-art review that assesses preoperative medical risk factors for complications in adult spinal deformity (ASD) surgery. The review includes evidence levels for various risk factors associated with complications in ASD surgery.

Target Population: The target population includes patients undergoing surgery for adult spinal deformity.

Key Factors:

• Methods: The study involved a literature search using the PubMed database to identify publications related to complications, risk factors, and adult spinal deformity. The included publications were assessed for the level of evidence as described in clinical practice guidelines published by the North American Spine Society.
• Results: The study found that frailty had good evidence (Grade A) as a risk factor for complications in ASD patients. Fair evidence (Grade B) was assigned for bone quality, smoking, hyperglycemia and diabetes, nutritional status, immunosuppression/steroid use, cardiovascular disease, pulmonary disease, and renal disease. Indeterminate evidence (Grade I) was assigned for pre-operative cognitive function, mental health, social support, and opioid utilization.
• Conclusions: Identifying risk factors for preoperative complications in ASD surgery is crucial for empowering informed choices for patients and surgeons and managing patient expectations. Risk factors with Grade A and B evidence should be identified prior to elective surgery and modified to reduce the risk of preoperative complications.

Selective Thoracolumbar/Lumbar Fusion in Adolescent Idiopathic Scoliosis: A Comprehensive Review of the Literature ⁽³⁾

Study Design: This study is a comprehensive review of the literature on selective thoracolumbar/lumbar fusion in adolescent idiopathic scoliosis (AIS).

Target Population: The target population includes adolescents with idiopathic scoliosis.

Key Factors:

• Introduction: AIS is a three-dimensional spine deformity leading to disability and various physical and psychological problems. Proper preoperative treatment is needed to improve appearance while maintaining spine function.
• Criteria for Selective TL/L Fusion: The study discusses the criteria for selective thoracolumbar/lumbar fusion, including Lenke's classification for AIS, which considers only structural curves in the fusion plan.
• Anterior or Posterior Approaches: The study compares the anterior and posterior approaches for selective TL/L fusion, highlighting the advantages and complications of each.
• Selective TL/L Fusion in Lenke Type 6: The study examines the outcomes of unfused structural thoracic curves following selective TL/L fusion in Lenke 6C AIS patients.
• Lowest Instrumented Vertebra Selection: The study discusses the selection of the lowest instrumented vertebra to maximize correction and movement.
• Sagittal Alignment: The study evaluates the sagittal plane in selective TL/L fusion, showing significant changes in various parameters preoperatively and postoperatively.
• Long-term Outcome: The study reviews the long-term outcomes, patient satisfaction, and complications of selective TL/L fusion.

Commentary: Appropriate Use Criteria for Lumbar Degenerative Scoliosis: Developing Evidence-based Guidance for Complex Treatment Decisions ⁽⁴⁾

Study Design: This study is a commentary on the development of Appropriate Use Criteria (AUC) for lumbar degenerative scoliosis, providing evidence-based guidance for complex treatment decisions.

Target Population: The target population includes patients with lumbar degenerative scoliosis.

Key Factors:

• Introduction: Lumbar degenerative scoliosis is a common problem treated more frequently due to an aging population and increased capacity to manage difficult problems in older patients. The condition often involves the intersection of degenerative spinal stenosis and spinal deformity.
• AUC Methodology: The RAND–UCLA Appropriateness Method was used to guide decision-making based on expert opinion and best available information. The method considers the expected health benefits and negative consequences of a procedure.
• Findings: The panel generated treatment recommendations for 260 clinical scenarios. Clinical scenarios with mild symptoms or limited stenosis and small deformities were generally deemed inappropriate for surgery. The most common clinical scenarios deemed appropriate for surgical treatment involved patients with moderate to severe leg pain or neurogenic claudication.
• Discussion: The study emphasizes the importance of evidence-based guidance for optimizing treatment for lumbar degenerative scoliosis. The AUC process aims to improve the quality and cost-effectiveness of care

ANALYSIS OF EVIDENCE
Shared Conclusions ^(3,4,6) :

All three studies emphasize the importance of evidence-based decision-making in spinal surgery. They highlight the need for careful assessment of risk factors, patient selection, and treatment criteria to optimize surgical outcomes and minimize complications.

Differing Conclusions:

• Arora et al. 2023 focuses on identifying and modifying preoperative risk factors for complications in ASD surgery, emphasizing the role of frailty, bone quality, and other medical conditions. ⁽⁶⁾
• Ghandhari et al. 2023 provides a detailed analysis of selective thoracolumbar/lumbar fusion in AIS, discussing various surgical approaches, criteria for fusion, and long-term outcomes. ⁽³⁾
• Glassman et al. 2017 develops Appropriate Use Criteria for lumbar degenerative scoliosis, providing a framework for making complex treatment decisions based on patient-specific factors and clinical scenarios. ⁽⁴⁾

In summary, while all three studies contribute valuable insights into spinal surgery, they each focus on different aspects of the field, from preoperative risk assessment to surgical techniques and treatment guidelines. This comprehensive analysis helps to reiterate the importance of tailored, evidence-based approaches in managing spinal deformities and optimizing patient outcomes.

References:

1.        Charles YP, Ntilikina Y. Scoliosis surgery in adulthood: what challenges for what outcome? Ann Transl Med. 2020;8(2):34. doi:10.21037/atm.2019.10.67

2.        North American Spine Society. Diagnosis and Treatment of Low Back Pain. NASS. Published online 2021. doi:https://www.spine.org/Portals/0/assets/downloads/ResearchClinicalCare/Guidelines/LowBackPain.pdf

3.        Ghandhari H, Ameri E, Nikouei F, Mahdavi SM, Chehrassan M, Motalebi M. Selective Thoracolumbar/Lumbar Fusion in Adolescent Idiopathic Scoliosis: A Comprehensive Review of the Literature. Arch Bone Jt Surg. 2023;11(5):313-320. doi:10.22038/abjs.2022.61439.3014

4.        Glassman SD, Berven SH, Shaffrey CI, Mummaneni P V, Polly DW. Commentary: Appropriate Use Criteria for Lumbar Degenerative Scoliosis: Developing Evidence-based Guidance for Complex Treatment Decisions. Neurosurgery. 2017;80(3):E205-E212. doi:10.1093/neuros/nyw094

5.        Smith JS, Kelly MP, Yanik EL, et al. Operative vs Nonoperative Treatment for Adult Symptomatic Lumbar Scoliosis at 8-Year Follow-Up: A Nonrandomized Clinical Trial. JAMA Surg. 2025;160(6):634-644. doi:10.1001/jamasurg.2025.0496

6.        Arora A, Cummins DD, Wague A, et al. Preoperative medical assessment for adult spinal deformity surgery: a state-of-the-art review. Spine Deform. 2023;11(4):773-785. doi:10.1007/s43390-023-00654-5

7.        Maitra S, Mikhail C, Cho SK, Daubs MD. Preoperative Maximization to Reduce Complications in Spinal Surgery. Global Spine J. 2020;10(1_suppl):45S-52S. doi:10.1177/2192568219882349

8.        Daniels AH, Singh M, Knebel A, et al. Preoperative Optimization Strategies in Elective Spine Surgery. JBJS Rev. 2025;13(2). doi:10.2106/JBJS.RVW.24.00210

9.        Rajaee SS, Kanim LEA, Bae HW. National trends in revision spinal fusion in the USA. Bone Joint J. 2014;96-B(6):807-816. doi:10.1302/0301-620X.96B6.31149

10.      North American Spine Society. Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. NASS. Published online 2011. doi:https://www.spine.org/Portals/0/Assets/Downloads/ResearchClinicalCare/Guidelines/LumbarStenosis.pdf

11.      Rajesh N, Moudgil-Joshi J, Kaliaperumal C. Smoking and degenerative spinal disease: A systematic review. Brain and Spine. 2022;2. doi:10.1016/j.bas.2022.100916

12.      Nunna RS, Ostrov PB, Ansari D, et al. The Risk of Nonunion in Smokers Revisited: A Systematic Review and Meta-Analysis. Global Spine J. 2022;12(3):526-539. doi:10.1177/21925682211046899

13.      Feeley A, McDonnell J, Feeley I, Butler J. Obesity: An Independent Risk Factor for Complications in Anterior Lumbar Interbody Fusion? A Systematic Review. Global Spine J. 2022;12(8):1894-1903. doi:10.1177/21925682211072849

14.      Cofano F, Perna G Di, Bongiovanni D, et al. Obesity and Spine Surgery: A Qualitative Review About Outcomes and Complications. Is It Time for New Perspectives on Future Researches? Global Spine J. 2022;12(6):1214-1230. doi:10.1177/21925682211022313

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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