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DESCRIPTIONFacet 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 patients with facet arthrosis, spinal stenosis, and spondylolisthesis.
POLICYTotal facet arthroplasty is considered investigational.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY11/11/2010: Approved by Medical Policy Advisory Committee.
08/03/2011: Policy reviewed; no changes.
09/25/2012: Policy reviewed; no changes.
10/17/2013: Policy reviewed; no changes to policy statement. Added ICD-9 procedure codes 84.84 and 84.85 to the Code Reference section.
SOURCE(S)Blue Cross Blue Shield Association policy # 7.01.120
This may not be a comprehensive list of procedure codes applicable to this policy.