Local Area Coverage Decisions
Local Area Coverage Decisions – Florida
Medicare in the State of Florida is administered by First Coast Service Options. Since January 1, 2012, certain operative procedures need to meet established criteria before physicians and hospitals will receive compensation. These criteria are established via the Local Area Coverage Decision. In regards to spinal surgery, these decisions are related to lumbar spinal fusions.
In order for a patient to qualify for lumbar spinal fusion, these are the necessary requirements:
1. For patients without prior surgery, only single level fusions qualify.
2. Patient must be a non-smoker.
3. Patient must have at least 3 months of documented and supervised physical therapy.
4. Life style changes including weight management, and activities modifications must be documented.
5. Criterion for fusions include instability, spondylolithesis, spondylolysis, single level DDD.
6. Patients with prior surgery, with developing instability can also meet criteria.
These are the general guidelines, and certain auditors for First Coast may have more liberal interpretation. But the take home message is that strict criteria need to be met, or else the Physician and the Hospital will not recieve compensation, even though the procedure has been performed.
Last modified: October 22, 2019
