LCD ID #L28991 AxiaLIF Spine Surgery a NONCOVERED Service

Local Coverage Determination (LCD) for AxiaLIF Spine Surgery

The presacral interbody technique (CPT codes 0195T, 196T, 0309T and 22586) (e.g. AxiaLIF) is noted as a noncovered service.

 

Some of the emerging techniques and associated tools (devices, spinal instrumentation, bone graft substitutes, etc.) are considered investigational and this LCD does NOT endorse such procedure.

 

 •  NOTE: An Advance Beneficiary Notice (ABN) is required for items and services not covered by Medicare

     due to being considered not medically reasonable and necessary.

           ◦  The beneficiary should be thoroughly educated about the benefits and risks of this item or service.

           ◦  If such notice is not given, providers may not shift financial liability for such items or services to beneficiaries

              should a claim for such items or services be denied by Medicare.

CPT/HCPCS Codes:

 0195T - Arthrodesis, pre-sacral interbody technique, including instrumentation, imaging (when performed), and

                discectomy to prepare interspace, lumbar; single interspace

 

 0196T - Arthrodesis, pre-sacral interbody technique, including instrumentation, imaging (when performed), and

                discectomy to prepare interspace, lumbar; each additional interspace (List separately in addition to code for

                primary procedure)

 

0309T - Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior

                instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (List

                separately in addition to code for primary procedure)

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