Lumbar Fusion - (Effective Date - 2026-10-15) 7.01.117

By October 1, 2026 (14 days before effective date): (1) Billing and clinical teams must immediately update authorization request templates and protocols to REQUIRE objective cotinine testing documentation (serum, urinary, or saliva confirmed within normal range) for ALL lumbar fusion cases submitted for pre-authorization—this is a mandatory gating criterion, not optional. (2) Update EMR and billing system workflows to flag/require nicotine status documentation at time of surgical planning; add checkbox fields for 'never smoker' status vs. '6+ weeks abstinence with cotinine test result' validation. (3) Educate providers and surgical coordinators that claims will be DENIED if nicotine-free status documentation (particularly objective cotinine results within 6 weeks of surgery) is missing, regardless of other clinical criteria being met. (4) Develop pre-op checklist requiring: imaging confirmation per specific criteria (Meyerding grade, spondylolisthesis type, deformity measurements, etc.), clinical symptom documentation, conservative treatment trial duration where applicable (3 months for degenerative spondylolisthesis without decompression), and completed cotinine test results. (5) Coordinate with referring physicians to provide cotinine test ordering guidance and expected timeline; communicate that surgery cannot proceed without validated test results. (6) Create internal audit process to verify all pre-auth submissions include cotinine documentation before forwarding to Excellus.