Anthem Blue Cross Connecticut SURG.00111 Axial Lumbar Interbody Fusion Form

This document addresses axial or presacral lumbar interbody fusion, a minimally invasive technique in which anterior access to the L4-S1 disc spaces is used for interbody fusion to minimize damage to muscular, ligamentous, neural, and vascular structures. It is performed under fluoroscopic guidance using specialized instrumentation.

Position Statement

Investigational and Not Medically Necessary:

Axial or presacral lumbar interbody fusion is considered investigational and not medically necessary.