Utilization Review Checklist
Lumbar Spondylolisthesis and Proven Segmental Instability
Derived from the ACOEM Low Back Disorders Guideline, edition 13 February 2020, as adopted into the California MTUS 23 November 2021. CPT 22612, 22630, 22633, 22558, 22800. ICD-10 M43.16, M43.17, M43.06, M43.07, M53.2X6, M53.2X7.
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
Required
Low back pain with documented instability
“Indications – LBP with documented instability.” — p. 171
Confirmatory Diagnosis
Any one of the following
At least 5 mm of translation of the superior vertebral body on the inferior body, from the full extension film to the full flexion film — at least 5
“The first criterion is ≥5mm of translation of the superior vertebral body on the inferior body from the full extension film to the full flexion films.” — p. 173
OR
Total angular movement during flexion and extension at the unstable level at least 20 degrees greater than the motion at an adjacent disc — at least 20
“The other criterion is having a total angular movement during flexion and extension at the unstable level that is at least 20 degrees greater than the motion present at an adjacent disc.” — p. 173
OR
Grade 3, 4 or 5 spondylolisthesis — at least 3
“Lumbar fusion is also indicated for grades 3, 4, and 5 spondylolisthesis” — p. 171
OR
Decompressive laminectomy at an area of degenerative instability, with coexisting spondylolisthesis or scoliosis
“a decompressive laminectomy at an area of degenerative instability as in the case of a coexisting spondylolisthesis or scoliosis when a discectomy is performed at the same level” — p. 171
Any one of the following:
A discectomy is performed at the same level
“a decompressive laminectomy at an area of degenerative instability as in the case of a coexisting spondylolisthesis or scoliosis when a discectomy is performed at the same level” — p. 171
OR
There is gross movement on flexion-extension radiographs
“a decompressive laminectomy performed at an area of degenerative instability, as in the case of a coexisting spondylolisthesis or scoliosis where there is gross movement on flexion-extension radiographs” — p. 171
OR
Adequate decompression requires removal of greater than 50% of both facets, or the complete removal of a unilateral facet complex — at least 50
“where an adequate decompression requires the removal of greater than 50% of both facets or the complete removal of a unilateral facet complex” — p. 171
Conservative Care(informational — not scored)
Required
Non-operative treatment to date is documented (no duration is specified by the guideline for this indication)
“Lumbar fusion is the most invasive of the commonly performed lumbar surgeries. It is high cost and has significant risks of complications.” — p. 173
Procedures — the guideline treats each separately
Lumbar fusion for isthmic spondylolisthesis
Recommended. Lumbar fusion is recommended as an effective treatment for isthmic spondylolisthesis.
Strength of Evidence — Recommended, Evidence (C) · confidence moderate · p. 171
Indications — required:
Isthmic spondylolisthesis is documented, with instability proven by one of the routes above
“Lumbar fusion is recommended as an effective treatment for isthmic spondylolisthesis.” — p. 171
Recommended as an effective treatment where instability is documented to the guideline's definition, or the slip is grade 3, 4 or 5.
Lumbar fusion for degenerative spondylolisthesis
Recommended. Lumbar fusion is recommended as an effective treatment for degenerative spondylolisthesis.
Strength of Evidence — Recommended, Evidence (C) · confidence moderate · p. 171
Indications — required:
Degenerative spondylolisthesis is documented, with instability proven by one of the routes above
“Lumbar fusion is recommended as an effective treatment for degenerative spondylolisthesis.” — p. 171
Recommended on the same indications as the isthmic form. State which diagnosis applies; the criteria do not differ.
Lumbar fusion for chronic non-specific low back pain
Moderately Not Recommended. Lumbar fusion is moderately not recommended as a treatment for chronic non-specific low back pain.
Strength of Evidence — Moderately Not Recommended, Evidence (B) · confidence moderate · p. 171
Indications — required:
The guideline moderately advises against fusion where the pain generator is not defined
“Lumbar fusion is moderately not recommended as a treatment for chronic non-specific low back pain.” — p. 171
Moderately NOT recommended. The guideline treats 'degenerative disc disease', 'discogenic back pain', 'black disc disease', 'micro instability' and 'lumbar spondylosis' as interchangeable labels for chronic low back pain with no defined pain generator. Using one of those terms does not convert this into an instability request — proven instability does.
Artificial disc replacement for chronic non-specific low back pain
Not Recommended. Artificial disc replacement is not recommended as a treatment for chronic non-specific low back pain or any other spinal pain syndrome.
Strength of Evidence — Not Recommended, Insufficient Evidence (I) · confidence low · p. 176
Indications — required:
The guideline advises against disc replacement for chronic non-specific low back pain or any other spinal pain syndrome
“Artificial disc replacement is not recommended as a treatment for chronic non-specific low back pain or any other spinal pain syndrome.” — p. 176
Not recommended, for chronic non-specific low back pain or any other spinal pain syndrome. Sits here alongside fusion for the same indication because a surgeon asking what can be offered for undifferentiated chronic low back pain needs both answers, and both are negative.