Utilization Review Checklist
Cervical Spinal Stenosis and Myelopathy
Derived from the ACOEM Cervical and Thoracic Spine Disorders Guideline, edition 17 October 2018, as adopted into the California MTUS 18 April 2019. CPT 63045, 63015, 63050, 63051, 22551, 22600. ICD-10 M48.02, M48.03, M47.12, M47.13, G95.20.
Draft — not reviewed or approved by COA. Prepared by Rette from the ACOEM guideline named above. This is not a COA document and does not reproduce COA’s own checklists.
CriteriaCheck if documented
Presumptive Diagnosis
Required
Neurogenic symptoms or objective neurologic deficit from cervical spinal stenosis
“neurogenic symptoms (e.g., upper extremity pain on neck movement, upper or lower limb ataxia, etc.) or objective neurologic deficit from cervical spinal stenosis” — p. 109
Confirmatory Diagnosis
Required
Imaging by MRI or CT confirming cervical spinal stenosis corresponding to the symptoms
“Recommendation: Decompression Surgery for Spinal Stenosis” — p. 109
Conservative Care
Required
Lack of responsiveness or unsatisfactory response to adequate non-operative treatment over a minimum 6 to 8 week period — at least 6 weeks
“lack of responsiveness or unsatisfactory response(s) to adequate non-operative treatment over a minimum 6 to 8 week period.” — p. 109
Procedures — the guideline treats each separately
Decompression surgery for symptomatic cervical spinal stenosis
Recommended. Decompression surgery is recommended for treatment of patients with symptomatic spinal stenosis that is intractable to non-operative management.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate · p. 109
Indications — required:
All three indications are documented
“Indications – All of the following should be present:” — p. 109
Recommended where the stenosis is symptomatic and intractable to non-operative management. The guideline notes myelopathic changes carry worse outcome prognoses — record them if present.
Decompression with fusion for symptomatic cervical spinal stenosis or myelopathy
Recommended. Decompression with fusion is recommended for treatment of patients with symptomatic spinal stenosis that is intractable to non-operative management.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate · p. 110
Indications — required:
The same indications are documented; the guideline states no additional requirement for adding fusion
“Decompression with fusion is recommended for treatment of patients with symptomatic spinal stenosis that is intractable to non-operative management.” — p. 110
Recommended on the same footing as decompression alone. The guideline leaves the anterior-versus-posterior approach and the fusion technique to the surgeon. Note it states NO separate indications for adding fusion here — unlike the Low Back chapter, which requires proven instability.