Medical Policy
Effective Date:12/07/2011 Title:Total Facet Arthroplasty
Revision Date: Document:BI325:00
CPT Code(s):0202T
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

  1. Facet Arthroplasty is proposed as an alternative to posterior spinal fusion for patients with Facet Arthrosis, Spinal Stenosis, and Spondylolisthesis. 
  2. There is no currently FDA approved device for this purpose, and this device is currently in clinical trials. 
  3. This technique is considered investigational.
Medical Statement

Total facet arthroplasty is considered investigational and is not covered.

 

Codes Used In This BI:

 

0202T, Posterior vertebral joint arthroplasty
Limits
Intentially left empty
Reference
Intentially left empty
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.