Bone Morphogenetic Proteins (bone morphogenic protein, BMP) for lumbar fusion and nonunion fracture of long bones

Coverage decision: Covered with Conditions

Conditions:

  • BMP must be directly for treatment of a condition accepted on the claim.
  • Lumbar fusions:
    • Bone morphogenetic protein-2 (rhBMP-2) is covered for use in the lumbar spine only
    • Adults 18 years of age and over; and,
    • For primary anterior open or laparoscopic fusion at one level between L4 and S1, OR
    • Revision lumbar fusion on a compromised patient for whom autologous bone and bone marrow harvest are not feasible or not expected to result in fusion
    • Bone morphogenetic protein-7 (rhBMP-7) is not covered for use in the lumbar spine
  • Long bone nonunions:
    • Bone morphogenetic protein-7 (rhBMP-7) is covered for use in recalcitrant long-bone nonunion fractures at least 9 months old and has not shown any signs of healing for 3 consecutive months.
    • Use of autograft is unfeasible, and
    • Alternative treatments have failed
    • Bone morphogenetic protein-2 (rhBMP-2) is not covered for use in long bone nonunion fractures.
  • BMP is not covered for use in the cervical spine or any other indication

Background Policy Information

Bone Morphogenetic Proteins (BMP) were reviewed for spinal fusion by the Washington State Health Technology Assessment Program’s State Health Technology Clinical Committee (HTCC) in 2013 and by the Office of the Medical Director (OMD) in L&I in 2003.

The State Health Technology Clinical Committee (HTCC) determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that BMP (rhBMP-2) for use in lumbar fusion is a covered benefit with conditions consistent with the criteria identified in the reimbursement determination. Complete information on this HTCC determination is available here: http://www.hca.wa.gov/hta/Pages/bmp.aspx

L&I’s OMD determined that Stryker Biotech's OP-1 Implant was covered as an alternative to autograft in recalcitrant long-bone nonunions where the use of autograft was unfeasible and alternative treatments had failed.  It was also determined that InFUSE Bone Graft with BMP-2 and LT-CAGE Lumbar Tapered Fusion Device system was covered for single-level anterior lumbar spine fusion in patients with degenerative disc disease at one level from L4-S1.

Implementation of the Determination

All requests for BMP for use in lumbar fusion and long-bone nonunion require prior authorization.

For State Fund Claims

To request utilization review for an inpatient procedure using either BMP-2 or BMP-7, please contact Qualis Health in any of the following ways:

Request of an outpatient procedure using BMP-7 will be reviewed by L&I’s occupational nurse consultant and claims manager:

  • Complete the Preauthorization Form and fax to:(360) 902-4567;
  • For additional information contact the claims manager
    • To obtain the claims manager’s phone number call 1-800-831-5227
    • Attending physician, concurrent care provider or IME log into the Claims & Account Center (CAC).
For Self-Insured Claims

For self-insured claims, contact the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIE/TPAs, go to:
http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp

Billing Codes

ICD-9 Procedure Codes:  84.52, 84.55
MS-DRG Codes:   M453-M460, M471-473


Health Care Authority's Health Technology Assessment Program site

For more information:
Contact information.

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