Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

Use the index below to search for coverage information on specific medical conditions.

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Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

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QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



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. Facet Arthroplasty is proposed as an alternative to posterior spinal fusion for patients with Facet Arthrosis, Spinal Stenosis, and Spondylolisthesis. There is no currently FDA approved device for this purpose, and this device is currently in clinical trials. 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
Background
A clinical trial sponsored by the device developer is publicly listed (on clinicaltrials.gov) as active, but not currently recruiting. The study is designed for patients with moderate to severe lumbar spinal stenosis requiring neural decompression with facetectomy at L3-L4 or L4-L5 at a single level to treat central or lateral stenosis, Grade I degenerative spondylolisthesis with objective evidence of neurologic impairment, and degenerative disease of the facets, with or without instability. Specific inclusion criteria are patients between 50 and 85 years of age with degenerative spinal stenosis, central or lateral, at spinal levels L3-L4 or L4-L5, with persistent leg symptoms, including pain, numbness, burning or tingling that are refractory to at least 6 months of conservative treatment, no greater than Grade I degenerative spondylolisthesis at the index level, and no more than three levels of degenerative lumbar spinal stenosis requiring decompression. Study participants will be randomized in a 2:1 ratio into treatment with the investigational artificial facet replacement device (TFAS™) or with standard posterior instrumented fusion. No device has received FDA approval; therefore, there is a lack of scientific evidence that Total Facet Arthroplasty is safe or improves health outcomes.
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.

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