Utilization Review Checklist
Cervical and Thoracic Fusion — Spondylolisthesis, Non-specific Pain, and Fusion Adjuncts
Derived from the ACOEM Cervical and Thoracic Spine Disorders Guideline, edition 17 October 2018, as adopted into the California MTUS 18 April 2019. CPT 22600, 22610, 22612, 22551, 20974, 20975. ICD-10 M43.12, M43.13, M43.14, M54.2, M54.6.
Draft — not reviewed or approved by COA. Prepared by Rette from the ACOEM guideline named above. This is not a COA document and does not reproduce COA’s own checklists.
CriteriaCheck if documented
Presumptive Diagnosis(informational — not scored)
Required
A specific diagnosis is documented
“Fusion is recommended for treatment of degenerative spondylolisthesis.” — p. 110
Procedures — the guideline treats each separately
Cervical or thoracic fusion for degenerative spondylolisthesis
Recommended. Fusion is recommended for treatment of degenerative spondylolisthesis.
Strength of Evidence — Recommended, Evidence (C) · confidence moderate · p. 110
Indications — required:
Degenerative spondylolisthesis is documented
“Fusion is recommended for treatment of degenerative spondylolisthesis.” — p. 110
Recommended in one sentence with no indications attached. Note the contrast with the Low Back chapter, which requires proven instability — at least 5 mm translation or 20 degrees of differential angular movement — for the same diagnosis. The cervical chapter asks for none of that. Documenting the slip and its grade anyway is the safer course.
Cervical or thoracic fusion for chronic non-specific cervical or thoracic pain
Not Recommended. Cervical fusion is not recommended for chronic non-specific cervical or thoracic pain.
Strength of Evidence — Not Recommended, Insuffcient Evidence (I) · confidence moderate · p. 112
Indications — required:
The guideline advises against fusion where the pain is non-specific
“Cervical fusion is not recommended for chronic non-specific cervical or thoracic pain.” — p. 112
Not recommended where the pain is non-specific. A defined diagnosis — radiculopathy, stenosis, spondylolisthesis — is what moves a request into a supported path.
Pulsed electromagnetic field stimulation as an adjunct to cervical spine fusion
Not Recommended. Pulsed electromagnetic field stimulation for cervical spine fusion is not recommended as a routine treatment for these patients, including patients with multiple spine fusion levels or in smokers.
Strength of Evidence — Not Recommended, Evidence (C) · confidence low · p. 111
Indications — required:
The guideline advises against this, including for multiple fusion levels and for smokers
“Pulsed electromagnetic field stimulation for cervical spine fusion is not recommended as a routine treatment for these patients, including patients with multiple spine fusion levels or in smokers.” — p. 111
Not recommended as routine treatment, and the guideline names the two groups usually argued for as exceptions — multiple fusion levels, and smokers — as still included in the finding.
Autologous platelet gel as an adjunct to cervical spine fusion
Not Recommended. Autologous platelet gel for cervical spine fusion is not recommended.
Strength of Evidence — Not Recommended, Evidence (C) · confidence low · p. 111
Indications — required:
The guideline advises against autologous platelet gel for cervical spine fusion
“Autologous platelet gel for cervical spine fusion is not recommended.” — p. 111
Not recommended. Stated without qualification.