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Medical Policy Axial Lumbosacral Interbody Fusion Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 404 BCBSA Reference Number: 7.01.130 NCD/LCD: NA Related Policies
• Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers), #584 • Interspinous Fixation - Fusion Devices, #436 • Total Facet Arthroplasty , #174 • Ultrasound Accelerated Fracture Healing Device, #497 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Axial lumbosacral interbody fusion (axial LIF) is considered INVESTIGATIONAL. Prior Authorization Information Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service.

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CPT Codes / HCPCS Codes / ICD Codes
Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The following CPT codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Codes CPT Codes Description 22586 Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace

Description Interbody Fusion Interbody fusion is a surgical procedure that fuses 2 adjacent vertebral bodies of the spine. Lumbar interbody fusion may be performed in patients with spinal stenosis and instability, spondylolisthesis, scoliosis, following a discectomy, or for adjacent-level disc disease. Axial Lumbosacral Interbody Fusion Axial lumbosacral interbody fusion (also called presacral, transsacral, or paracoccygeal interbody fusion) is a minimally invasive technique designed to provide anterior access to the L4-S1 disc spaces for interbody fusion while minimizing damage to muscular, ligamentous, neural, and vascular structures. It is performed under fluoroscopic guidance.

An advantage of axial lumbosacral interbody fusion is that it preserves the annulus and all paraspinous soft tissue structures. However, there is an increased need for fluoroscopy and an inability to address intracanal pathology or visualize the discectomy procedure directly. Complications of the axial approach may include perforation of the bowel and injury to blood vessels and/or nerves.

Summary
Axial lumbosacral interbody fusion (also called presacral, transsacral, or paracoccygeal interbody fusion) is a minimally invasive technique designed to provide anterior access to the L4-S1 disc spaces for interbody fusion while minimizing damage to muscular, ligamentous, neural, and vascular structures. It is performed under fluoroscopic guidance. For individuals who have degenerative spine disease at the L4-S1 disc spaces who receive axial lumbosacral interbody fusion, the evidence includes a comparative systematic review of case series and a retrospective comparative study. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The systematic review found that fusion rates were higher following transforaminal lumbosacral interbody fusion than following axial lumbosacral interbody fusion, although this difference decreased with use of bone morphogenetic protein or pedicle screws. The findings of this systematic review were limited by the lack of prospective comparative studies and differences in how fusion rates were determined. Studies have suggested that complication rates may be increased with 2- level axial lumbosacral interbody fusion. Controlled trials with clinical outcome measures are needed to better define the benefits and risks of this procedure compared with treatment alternatives. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

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Policy History Date Action 5/2026 Policy updated with literature review through March 11, 2026; no references added. Policy statement unchanged. 6/2025 Annual policy review. References updated. Policy statements unchanged. 6/2024 Annual policy review. References updated. Policy statements unchanged. 6/2023 Annual policy review. Policy statements unchanged. 6/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 5/2021 BCBSA National medical policy review. Description, summary, and references updated. Policy statements unchanged. 6/2020 BCBSA National medical policy review. Description, summary and references updated. Policy statements unchanged. 5/2019 BCBSA National medical policy review. Description, summary and references updated. Policy statements unchanged. 1/2019 Clarified coding information. 1/2018 Clarified coding information. 5/2016 New references added from BCBSA National medical policy. 12/2015 Added coding language. 12/2014 New references added from BCBSA National medical policy. 2/2014 New references added from BCBSA National medical policy. 12/2012 Updated to add new CPT code 22586. 9/2012 Updated with New medical policy describing ongoing non-coverage. Information was transferred from medical policy 617, Minimally Invasive Lumbar Interbody Fusion.
1/2012 Reviewed at MPG – Neurology and Neurosurgery, no changes in coverage were made. 12/1/2011 New policy, effective 12/1/2011 Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. U.S. Food and Drug Administration. Premarket Notification [510(K)] Summary. TranS1 AxiaLIF Fixation System. 2007; https://www.accessdata.fda.gov/cdrh_docs/pdf7/K073514.pdf. Accessed March 10, 2026.
2. U.S. Food and Drug Administration. Premarket Notification [510(K)] Summary. TranS1 AxiaLIF II System. 2008; https://www.accessdata.fda.gov/cdrh_docs/pdf7/K073643.pdf. Accessed March 11,
4. Shen FH, Samartzis D, Khanna AJ, et al. Minimally invasive techniques for lumbar interbody fusions. Orthop Clin North Am. Jul 2007; 38(3): 373-86; abstract vi. PMID 17629985
5. Schroeder GD, Kepler CK, Millhouse PW, et al. L5/S1 Fusion Rates in Degenerative Spine Surgery: A Systematic Review Comparing ALIF, TLIF, and Axial Interbody Arthrodesis. Clin Spine Surg. May 2016; 29(4): 150-5. PMID 26841206
6. Whang PG, Sasso RC, Patel VV, et al. Comparison of axial and anterior interbody fusions of the L5- S1 segment: a retrospective cohort analysis. J Spinal Disord Tech. Dec 2013; 26(8): 437-43. PMID 24196923

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6. Tobler WD, Gerszten PC, Bradley WD, et al. Minimally invasive axial presacral L5-S1 interbody fusion: two-year clinical and radiographic outcomes. Spine (Phila Pa 1976). Sep 15 2011; 36(20): E1296-301. PMID 21494201
7. Zeilstra DJ, Miller LE, Block JE. Axial lumbar interbody fusion: a 6-year single-center experience. Clin Interv Aging. 2013; 8: 1063-9. PMID 23976846
8. Gerszten PC, Tobler W, Raley TJ, et al. Axial presacral lumbar interbody fusion and percutaneous posterior fixation for stabilization of lumbosacral isthmic spondylolisthesis. J Spinal Disord Tech. Apr 2012; 25(2): E36-40. PMID 21964453
9. Marchi L, Oliveira L, Coutinho E, et al. Results and complications after 2-level axial lumbar interbody fusion with a minimum 2-year follow-up. J Neurosurg Spine. Sep 2012; 17(3): 187-92. PMID 22803626
10. Gundanna MI, Miller LE, Block JE. Complications with axial presacral lumbar interbody fusion: A 5- year postmarketing surveillance experience. SAS J. 2011; 5(3): 90-4. PMID 25802673
11. Lindley EM, McCullough MA, Burger EL, et al. Complications of axial lumbar interbody fusion. J Neurosurg Spine. Sep 2011; 15(3): 273-9. PMID 21599448
12. North American Spine Society. Diagnosis and treatment of degenerative lumbar spondylolisthesis. 2nd Ed. 2014; https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/Spondylolisthesis.pdf. Accessed March 11, 2026.
13. National Institute for Health and Care Excellence (NICE). Transaxial interbody lumbosacral fusion for severe chronic low back pain [HTG478]. 2018; https://www.nice.org.uk/guidance/htg478. Accessed March 11, 2026.