BlueCross BlueShield of Tennessee Medical Policy Manual

Facet Arthroplasty

DESCRIPTION

Facet arthroplasty refers to the implantation of a spinal prosthesis to restore posterior element structure and function as an adjunct to neural decompression. This procedure is proposed as an alternative to posterior spinal fusion for individuals with facet arthrosis, spinal stenosis, and spondylolisthesis.  No facet arthroplasty devices are approved by the U.S. Food and Drug Administration (FDA) at this time.

POLICY

IMPORTANT REMINDERS

SOURCES

BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2017). Facet arthroplasty (7.01.120). Retrieved October 9, 2017 from BlueWeb. (2 articles and/or guideline reviewed)

Dahl, M., & Freeman, A. (2016). Kinematic and fatigue biomechanics of an interpositional facet arthroplasty device. Spine Journal, 16 (4), 531-539. Abstract retrieved December 12, 2016 from PubMed database.

National Government Services, Inc. (2016, October). LCD: Category III CPT codes (L33392). Retrieved December 12, 2016 from   https://www.cms.gov/medicare-coverage-database/license/cpt-license.aspx

Sjovold, S., Zhu, Q., Bowden, A., Larson, C., de Bakker, P., Villarraga, M., et al. (2012). Biomechanical evaluation of the total facet arthroplasty system (TFAS): loading as compared to a rigid posterior instrumentation system. European Spine Journal, 2012, 21:1660-1673. (Level 4 evidence)

ORIGINAL EFFECTIVE DATE:  1/9/2010

MOST RECENT REVIEW DATE:  11/9/2017

ID_BA

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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