Coverage Policies

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)

Interbody fusion (arthrodesis) in the lumbar spine is performed to treat painful symptoms caused by instability of the vertebrae, such as spondylolisthesis, spinal stenosis, or degenerative disc disease. Methods of spinal fusion include bone grafts or metal implants placed either anteriorly, posteriorly, or laterally; however, insertion of these implants is not without surgical risk. Numerous open and minimally invasive techniques have been developed but all of these approaches experience the same shortcomings related to biomechanics or inherent iatrogenic destabilization.

In an attempt to alleviate many of the limitations of previous techniques, a pre-sacral approach to the lumbosacral junction has been investigated. Transaxial anterior lumbar interbody fusion is an emerging minimally invasive spinal fusion procedure used to treat patients with chronic lower back pain (Ollendorf, et al., 2011). This procedure is an alternative to traditional fusion techniques that utilize anterior or posterior approaches to directly expose the lumbosacral spine. In the case of transaxial anterior lumbar interbody fusion the spine is accessed percutaneously via the anterior surface of the sacrum.

Percutaneous AxiaLIF (also called anterior para-axial, trans-sacral or paracoccygeal interbody fusion, performed with the AxiaLIF® and AxiaLIF 2 Level systems) is a minimally invasive technique that uses axial access to the L5-S1 disc spaces. Under fluoroscopic monitoring, a guide pin is passed through a small (15- to 20-mm) incision lateral to the coccyx and advanced along the midline of the anterior surface of the sacrum. A series of graduated dilators is passed along the guide pin, which serves as a working channel for the passage of instruments. Under fluoroscopic guidance, the nucleus pulposus is debulked and bone graft material is injected through a threaded rod to fill the disc space. Percutaneous pedicle or facet screws are also used. Although the procedure may minimize damage to adjacent tissue, it is performed entirely under indirect visualization with fluoroscopy and is not able to address posterior element pathology.

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