That's typical for all types of spinal surgeries. I did utilization review for workers comp cases before retiring. We had protocols that had to be followed -- set up by the various insurance companies -- before we could approve an orthopedic surgery (most of the cases were orthopedic). Torn rotator cuff? PT, injections, NSAIDs. Diagnostics showing the acute injury. Specific measurements of lack of function, as well as continuing pain. Only then could we approve a surgical repair. Ditto for spinal injuries whether cervical or lumber. PT, medication, epidural steroid injections, then possibly a fusion if these treatments were ineffective. As nurses we were unable to approve fusions so our peer review physicians did that. The insurance companies were all private corporations; none of this was government.