Policy library

All other reasonable sources of pain and/or neurological deficit have been ruled out, including but not limited to significant pathology at other spinal level(s) on the advanced imaging radiology report that is/are not part of the surgical request resulting in incomplete surgical planning

Cited span“isolated to the right”

Member has signs or symptoms of neural compression (radiculopathy, neurogenic extremity claudication, myelopathy) associated with the levels being treated

Cited span“positive right straight-leg raise”

Advanced imaging studies (CT or MRI) indicate central/lateral recess or foraminal stenosis (graded as moderate, moderate to severe or severe; not mild or mild to moderate), or nerve root or spinal cord compression, at the level corresponding with the clinical findings

Cited span“moderate-to-severe right lateral recess narrowing”

Member has failed at least 6 weeks of conservative therapy

Cited span“past 10 weeks”

Conservative measures were recent (within the past year)

Cited span“July to September 2026”

Active in-person physical therapy (not home or virtual) for the entire required duration, confirmed by the actual PT notes or by documentation in the member claims history

Named gapRequired: in-person physical therapy. No chart span supports it.

Trial of medications (NSAIDs, acetaminophen, or tricyclic antidepressants)

Cited span“naproxen 500 mg”

Patient education provided

Cited span“written lumbar self-care education”

Member's activities of daily living are limited by symptoms of neural compression

Cited span“unable to work his delivery-driver shifts”