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.    Pre-sacral arthrodesis (AxiaLIF) is the use of a minimally invasive system for fusion of lower vertebrae.

2.    AxiaLIF is considered Experimental/ Investigational and is not a covered benefit.

Axial lumbar interbody fusion (AxiaLIF), a percutaneous pre-sacral access route to the L4 – S1 vertebral bodies for spinal fusion, is considered experimental and investigational because of insufficient evidence of its effectiveness.

Codes Used In This BI:

22586   Arthrodesis, pre-sacral interbody technique, incl disc spc prep, discectomy, 

             w/posterior instrmnt, w/img guid, incl bone graft when perf, L5 – S1 intrspc

22899   Unlisted procedure of spine (i.e. Arthrodesis, pre-sacral interbody tech, disc spc

             prep, discectomy, w/out instrmnt, w/img guid, incl bone graft when perf; L4 – L5

             and/or L5 – S1 intrspc)

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11. Gerszten PC, Tobler WD, Nasca RJ. Retrospective analysis of L5-S1 axial lumbar interbody fusion (AxiaLIF): A comparison with and without the use of recombinant human bone morphogenetic protein-2. Spine J. 2011;11(11):1027-1032.
12. Gerszten PC, Tobler W, Raley TJ, et al. Axial presacral lumbar interbody fusion and percutaneous posterior fixation for stabilization of lumbosacral isthmic spondylolisthesis. J Spinal Disord Tech. 2012;25(2):E36-E40.
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