Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Use the index below to search for coverage information on specific medical conditions.

High-Tech Imaging: High-Tech Imaging services are administered by Evolent. For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 04/01/2013 Title: Spinal Surgery
Revision Date: 10/01/2020 Document: BI394:00
CPT Code(s): 20552, 20553, 20690, 20692, 20693, 20694, 20900, 20902, 20926, 20930, 20931, 20932, 20933, 20934, 20936, 20937, 20938, 20939, 20955, 20962, 20974, 20975, 20979, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22552, 22554, 22556, 22558, 22585, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22818, 22819, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22855, 22864, 22865, 27080, 27096, 27279, 27280, 62263, 62264, 62267, 62280, 62281, 62282, 62287, 62292, 62302, 62303, 62304, 62305, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62328, 62329, 62380, 63003, 63005, 63012, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63053,63055, 63056, 63057, 63064, 63066, 63075, 63077, 63076, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, 64420, 64421, 64450, 64451, 64454, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636, 64712, 69990, 0200T, 0201T, 0202T, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0219T, 0220T, 0221T, 0222T, 0274T, 0275T, 0481T, C1821, C2614, C9752, C9753, C9757, G0259, G0260, G0276, S2348, S2350, S2351
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    For Cervical Spinal surgery, please refer to MCG Care guidelines.

2)    For intervertebral disc prosthesis. please refer to BI 182

3)    Lumbar spinal fusion requires pre-authorization.

4)    Lumbar fusion is a procedure for the treatment of significant low back pain that has not improved after extensive therapy or is the result of significant spine deformity.

5)    Sacroiliac fusion for low back pain is not covered.  Sacroiliac fusion is considered experimental/investigational based on the low quality of research showing benefits for patients with low back pain.

Please see criteria for conservative management and waiver of conservative management in medical policy section below.


Medical Statement

Following surgical procedures including Lumbar spinal fusion require pre-authorization:

CPT 20932, 20933,20934, 20939, 20974, 20975, 20979, 22100, 22101, 22102, 22110, 22112, 22114, 22206, 22207, 22210, 22212, 22214, 22220, 22222, 22224, 22532, 22533, 22552, 22554, 22556, 22558, 22600, 22610, 22612, 22630, 22633, 22864, 22865, , , 62380, 63003, 63005, 63012, 63016, 63017, 63020, 63030, 63040, 63042, 63045, 63046, 63047, 63055, 63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, C9757).

Thoracic laminectomy (CPT 63003, 63016, 63046) (and/or thoracic diskectomy and fusion) (63077, 22222, 22532, 22556) require prior authorization and are considered medically necessary for individuals with herniated discs or other causes of thoracic nerve root compression (osteophytic spurring, ligamentous hypertrophy) when all of the following criteria are met:

1)    All other reasonable sources of pain have been ruled out; and

2)    Presence of thoracic pain secondary to nerve root or spinal cord compression with findings of weakness, myelopathy, or sensory deficit; and

3)    Imaging studies (e.g., 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; and

4)    Member has failed at least 8 weeks of conservative therapy (unless there is evidence of thoracic cord compression, or other indications for waiver of requirements for conservative management, noted below); and

5)    Member has physical and neurological abnormalities confirming the historical findings of nerve root or spinal cord compression (e.g., reflex change, sensory loss, weakness) at or below the level of the lesion and may have gait or sphincter disturbance (evidence of thoracic radiculopathy or myelopathy); and

6)    Member`s activities of daily living are limited by persistent pain.

Lumbar laminectomy (63005, 63012, 63016, 63047) requires prior authorization and is considered medically necessary for individuals with a herniated disc when all of the following criteria are met:

1)    All other reasonable sources of pain have been ruled out; and

2)    Imaging studies (e.g., 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; and

3)    Member has failed at least 6 weeks of conservative therapy (unless there is evidence of spinal cord compression or other indications for waiver of requirements for conservative management, noted below); and

4)    Member`s activities of daily living are limited by persistent pain radiating from the back down to the lower extremity; and

5)    Presence of neurological abnormalities (e.g., reflex change, positive straight leg raising, sensory loss, weakness) persist on examination and correspond to the specific affected nerve root.

 

QualChoice considers lumbar or thoracic laminectomy medically necessary for any of the following:

1)    Spinal fracture, dislocation (associated with mechanical instability), locked facets, or displaced fracture fragment confirmed by imaging studies (e.g., CT or MRI); or

2)    Spinal infection confirmed by imaging studies (e.g., CT or MRI); or

3)    Spinal tumor confirmed by imaging studies (e.g., CT or MRI); or

4)    Epidural hematomas confirmed by imaging studies (e.g., CT or MRI); or

5)    Synovial cysts, or arachnoid cysts causing spinal cord or nerve root compression with unremitting pain, confirmed by imaging studies (e.g., CT or MRI) and with corresponding neurological deficit, where symptoms have failed to respond to eight weeks of conservative therapy (unless there is evidence of cord compression, or other indications for waiver of requirements for conservative management, noted below) or

6)    Spinal stenosis (central, lateral recess or foraminal stenosis) graded as moderate, moderate to severe or severe (not mild or mild to moderate) with unremitting pain, with stenosis confirmed by imaging studies (e.g., CT or MRI) at the level corresponding to neurological findings, where symptoms have failed to respond to eight weeks conservative therapy (unless there is evidence of cord compression, or other indications for waiver of requirements for conservative management, noted below); or

7)    Other mass lesions confirmed by imaging studies (e.g., CT or MRI), upon individual case review.

 

Lumbar decompression with or without discectomy requires prior authorization and is considered medically necessary for rapid progression of neurological impairment (e.g., foot drop, extremity weakness, saddle anesthesia, bladder dysfunction or bowel dysfunction) with central, lateral recess or foraminal stenosis (graded as moderate, moderate to severe or severe; not mild or mild to moderate) (CPT 63056) confirmed by imaging studies (e.g., CT or MRI) at the levels corresponding to the neurologic findings.

 

Vertebral corpectomy (removal of half or more of vertebral body, not mere removal of osteophytes and minor decompression) (63081, 63085, 63087, 63090, 63101, 63102, 63103, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307) requires prior authorization and is considered medically necessary in the treatment of one of the following:

1)    For tumors involving one or more vertebrae, or

2)    Greater than 50 % compression fracture of vertebrae, or

3)    Retropulsed bone fragments, or

4)    Symptomatic moderate or greater central canal stenosis caused by vertebral body pathology (such as due to fracture, tumor or congenital or acquired deformity of the vertebral body).

Lumbar spinal fusion (22558, 22612, 22630, 22633) requires prior authorization and is considered medically necessary for the following:

1)    Spinal fracture repair resulting in:

a)    Spinal instability (e.g. burst fracture); or

b)    Neural compression.

2)    Treatment of spinal stenosis with all of the following criteria:

a)    Postoperative instability is likely due to extent of disease or surgery (e.g. multiple levels); and

b)    Significant stenosis demonstrated radiographically where Imaging studies (e.g., 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;

c)    Stenosis treatment indicated by 1 or more of the following:

i)     Progressive or severe symptoms of neurogenic claudication; or

ii)    Leg or buttock claudication symptoms and all of the following:

·         Symptoms are disabling; and

·         Symptoms correlate with imaging findings; and

·         Persistence of symptoms for 3 months or more; and

·         Failure of 8 weeks of intense conservative therapy to include:

(a)  Active, organized and progressive strength and flexibility program to include formal physical therapy; and

(b)  Less than 30% improvement in the Oswestry Disability Index (ODI)1 or Focus On Therapeutic Outcomes (FOTO)  during the conservative therapy; and

(c)  ODI preoperatively is between 40% and 79% of FOTO is between 21 – 60.
A link to ODI is available here;
http://www.rehab.msu.edu/_files/_docs/Oswestry_Low_Back_Disability.pdf

3)    Lumbar spondylolisthesis with one or more of the following:

a)    Progressive or severe neurologic deficits (e.g. bowel or bladder dysfunction); or

b)    Treatment is indicated by all of the following:

i)     Persistent disabling symptoms including:

·         Low back pain; or

·         Neurogenic claudication; or

·         Radicular pain; and

ii)    Listhesis of at least grade 2 is demonstrated on imaging; or radiographic documentation dynamic instability of at least 4 mm of translation or 10 degrees of angular motion on dynamic imaging and

iii)   Symptoms correlate with the imaging findings; and

iv)   Symptoms have been present at least 3 months; and

v)    Failures of 8 weeks of intense conservative therapy; see above.

4)    Chronic disco genic back pain with all of the following:

a)    Radicular pain; and

b)    Pain and disability for at least 1 year; and

c)    MRI evidence of nerve root impingement consistent with the clinical findings; and

d)    Failure of 8 weeks of intense conservative therapy (see above).

5)    Child or adolescent with high grade (>50% slippage) spondylolisthesis.

6)    Spinal repair and fusion in conjunction with other procedures for neural decompression, fracture, dislocation, infection, abscess or tumor

7)    Adult scoliosis confirmed by imaging studies, with Cobb angle greater than 50 degrees associated with functional impairment in skeletally mature adults, that has failed 3 months of conservative management (unless there is evidence of lumbar cord compression, or other indications for urgent intervention, noted below); or

8)    Adult kyphosis or which is associated with radiological (e.g., CT or MRI) evidence of mechanical instability or deformity of the lumbar spine that has failed 3 months of conservative management (unless there is evidence of lumbar cord compression, or other indications for urgent intervention, noted below); or

9)    Lumbar pseudarthrosis (defined as absence of bridging bone that connects the vertebrae) after 12 months have elapsed since the time of fusion (unless there is evidence of lumbar cord compression, or other indications for urgent intervention, noted below), or if there is pseudarthrosis with additional findings of hardware failure (movement of implants or vertebrae at site of prior attempted arthrodesis on dynamic radiographs, or imaging evidence of fracture/disconnection/dislocation of implants, or lucent rims around the screws on CT scan) (Note: For lumbar pseudoarthrosis not associated with hardware failure or indications for urgent intervention, there should be documentation of nicotine cessation, including a nicotine blood level for persons with recent nicotine use (unless there is evidence of lumbar cord compression, or other indications for urgent intervention, noted below));

 

Thoracic spinal fusion (CPT 22556, 22610) requires prior authorization and is considered medically necessary for any of the following:

1)         Scoliosis confirmed by imaging studies, with Cobb angle greater than 40 degrees in skeletally immature children and adolescents, or Cobb angle greater than 50 degrees associated with functional impairment in skeletally mature adults, that has failed 3 months of conservative management (unless there is evidence of thoracic cord compression, or other indications for urgent intervention, noted below); or

2)         Thoracic kyphosis resulting in spinal cord compression, or kyphotic curve greater than 75 degrees that is refractory to bracing, that has failed 3 months of conservative management (unless there is evidence of thoracic cord compression, or other indications for urgent intervention, noted below); or

3)         Thoracic pseudarthrosis (defined as absence of bridging bone that connects the vertebrae) after 12 months have elapsed since the time of fusion (unless there is evidence of thoracic cord compression, or other indications for urgent intervention, noted below), or if there is pseudarthrosis with additional findings of hardware failure (movement of implants or vertebrae at site of prior attempted arthrodesis on dynamic radiographs, or imaging evidence of fracture/disconnection/dislocation of implants, or lucent rims around the screws on CT scan); or

4)         Spinal fracture, dislocation (associated with mechanical instability), locked facets, or displaced fracture fragment confirmed by imaging studies (e.g., CT or MRI), which may be combined with a laminectomy; or

5)         Spinal infection confirmed by imaging studies (e.g., CT or MRI) and/or other studies (e.g., biopsy), which may be combined with a laminectomy; or

6)         Spinal tumor, primary or metastatic to spine, confirmed by imaging studies (e.g., CT or MRI), which may be combined with a laminectomy; or

7)         Spondylolisthesis with segmental instability confirmed by imaging studies (e.g., CT or MRI), when both of the following criteria are met:

          a) Significant spondylolisthesis, grades II, III, IV, or V and

         b) Symptomatic unremitting pain that has failed eight weeks of conservative management (unless there is evidence of thoracic cord compression, or other indications for urgent intervention, noted below); or

8)         Spinal stenosis where criteria for thoracic decompression in Section above are met, and any of the following is met:

            a) Decompression is performed in an area of segmental instability as manifested by gross movement on flexion-extension radiographs; or

            b) Decompression coincides with an area of significant degenerative instability (e.g., scoliosis or any degree of spondylolisthesis (grades I, II, III, IV or V); or

c) Decompression creates an iatrogenic instability by the disruption of the posterior elements where facet joint excision exceeds 50% bilaterally or complete excision of one facet is performed.

Conservative Management:

Conservative management must be recent (within the past year) and include the following non-surgical measures and medications unless neurologic signs are severe or rapidly progressive:

Patient education;

Low impact exercise as tolerated (e.g., stationary bike, swimming, walking),

Active physical therapy for at least 6 weeks;

Medications (NSAIDS, acetaminophen, or tricyclic antidepressants),

and (where appropriate) identification and management of associated anxiety and depression.

Note: The member must participate in physical therapy for a minimum of 6 weeks duration as part of the conservative management, unless s/he meets criteria below for urgent intervention.

The requirement for a trial of conservative measures may be waived in the following situations indicating need for urgent intervention:

Spinal cord compression or stenosis causing any of the following:

1.    cauda equina syndrome,

2.    myelopathy,

3.    severe muscle weakness (graded 4 minus or less on MRC scale (Note: 4 minus strength describes muscle activation that is beyond antigravity (3/5) and produces motion against only slight resistance and fails against moderate resistance);

4.    Instability (dynamic excursion of greater than 1mm translation or greater than 5 degrees angulation at an interspace);

5.    progressive neurological deficit on serial examinations; or

6.    A discharge note from a physical therapist documents lack of utility of further physical therapy.

 

NOTE: QualChoice considers the official written report of complex imaging studies (e.g., CT, MRI, myelogram) for medical necessity reviews. If the operating surgeon disagrees with the official written report, the surgeon should document that disagreement. The surgeon should discuss the disagreement with the provider who did the official interpretation, and there should also be a written addendum to the official report indicating agreement or disagreement with the operating surgeon. The imaging should be performed within the past year, or after the onset of the current constellation of symptoms or any relevant surgical procedures, whichever is sooner.

The following procedures are considered experimental/investigational, therefore are not covered:

-       27279, 27280 – arthrodesis of sacroiliac joint.

-       0201T – sacroplasty

-       0202T- Posterior vertebral joint(s) arthroplasty

-       0219T, 0220T, 0221T, 0222T, placement of posterior intrafacet implant

-       0481T injections of autologous white blood cell concentrate

-       0274T, 0275T  Percutaneous laminotomy/laminectomy

-       22867, 22868, 22869, 22870 and HCPC C1821 Interspinous/interlaminar process stabilization/spacer device and its removal.

Codes Used In This BI:

 

20552

Inj(s); sgl or mult trigger point(s), 1-2 muscles(s) [no repeats > every 7 days, up to 4 sets to diagnose & achieve therap effect, no addtl sets if no clinical resp, once diagnosed & therapeutic effect achieved, no repeats > 1 every 2 mths, & beyond 12 mths req clinical rvw]

 

20553

Inj(s); sgl or mult trigger point(s), 3+ muscles(s) [no repeats > every 7 days, up to 4 sets to diagnose & achieve therap effect, no addtl sets if no clinical response, once diagnosed & therap effect achieved, no repeats > 1 every 2 mths, & beyond 12 mths req clinical rvw]

 

20690

Application of a uniplane, unilat, extrnl fixatn syst

 

20692

Application of a multiplane, unilat, extrnl fixatn syst

 

20693

Adjstmt or revsn of extrnl fixatn syst req anesthesia &/or new ring(s) or bar(s)

 

20694

Remvl, under anesthesia, of extrnl fixatn syst

 

20900

Bone graft, any donor area; minor or small (e.g., dowel or button)

 

20902

Bone graft, any donor area; major or large

 

20926

Tissue grafts, other (e.g., paratenon, fat, dermis) [not cvd during lumbar dcmprsn laminectomy/discectomy] Deleted code eff 01/01/2020

+

20930

Allograft, morselized, or plcmnt of osteopromotive material, for spine surgery only

+

20931

Allograft, structural, for spine surgery only

+

20932

Allograft, incl templating, cutting, plcmnt & intrnl fixatn, when perf; osteoarticular, incl articular surface & contiguous bone

+

20933

Allograft, incl templating, cutting, plcmnt & intrnl fixatn, when perf; hemicortical intercalary, partial (i.e., hemicylindrical)

+

20934

Allograft, incl templating, cutting, plcmnt & intrnl fixatn, when perf; intercalary, complete (i.e., cylindrical)

+

20936

Autograft for spine surgery only; local obtained frm same incision

+

20937

Autograft for spine surgery only; morselized (thru sep skin or fascial incision)

+

20938

Autograft for spine surgery only; structural, bicortical or tricortical (thru sep skin or fascial incsn)

+

20939

Bone marrow aspiration for bone autografting, spine surgery only

 

20955

Bone graft with microvascular anastomosis; fibula

 

20962

Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal

 

20974

Electrical stimulation to aid bone healing; noninvasive (nonoperative)

 

20975

Electrical stimulation to aid bone healing; invasive (operative)

 

20979

Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)

+

22103

Partl excsn of posterior vrtbrl component (e.g., spinous process, lamina or facet) for intrinsic bony lesion, sgl vrtbrl sgmt; ea addl sgmt

+

22116

Partl excsn of vrtbrl body, for intrinsic bony lesion, w/o dcmprsn of spinal cord or nerve root(s), sgl vrtbrl sgmt; ea addtl vrtbrl sgmt

+

22208

Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vrtbrl sgmt; ea addtl vrtbrl sgmt

+

22216

Osteotomy of spine, posterior or posterolateral approach, 1 vrtbrl sgmt; ea addtl vrtbrl sgmt

+

22226

Osteotomy of spine, incl discectomy, anterior appr, sgl vrtbrl sgmt; ea addtl vrtbrl sgmt

 

22533

Arthrodesis, lateral extracavitary techn, incl minimal discectomy to prepare intrspc (othr than for dcmprsn); lumbar

+

22534

Arthrodesis, lateral extracavitary techn, incl minimal discectomy to prepare intrspc (othr than for dcmprsn); thoracic or lumbar, ea addtl vrtbrl sgmt

+

22552

Arthrodesis, anterior interbody, incl disc space prep, discectomy, osteophytectomy & dcmprsn of spinal cord &/or nerve roots; cervical below C2, ea addtl intrspc

 

22558

Arthrodesis, anterior interbody techn, incl minimal discectomy to prepare intrspc (other than for decmprsn); lumbar

+

22585

Arthrodesis, anterior interbody techn, incl minimal discectomy to prepare intrspc (other than for dcmprsn); ea addtl intrspc

 

22612

22610

Arthrodesis, posterior or posterolateral techn, sgl lvl; lumbar (w/lateral trnsvrs techn, when perf)

Arthrodesis, post or posterolateral tech, single level; thoracic (w/lateral transverse tech, when performed)

+

22614

Arthrodesis, posterior or posterolateral techn, sgl lvl; ea addtl vrtbrl sgmt

 

22630

Arthrodesis, posterior interbody techn, incl laminectomy &/or discectomy to prepare intrspc (other than for dcmprsn), sgl intrspc; lumbar

+

22632

Arthrodesis, posterior interbody technique, incl laminectomy &/or discectomy to prepare intrspc (other than for dcmprsn), sgl intrspc; ea addtl intrspc

 

22633

Arthrodesis, combined posterior or posterolateral techn w/posterior interbody techn incl laminectomy &/or discectomy sufficient to prepare intrspc (other than for dcmprsn), sgl intrspc & sgmt; lumbar

 

22818

Kyphectomy, circumferential exposure of spine & resection of vrtbrl sgmt(s) (incl body & posterior elements); sgl or 2 sgmts 

 

22819

Kyphectomy, circumferential exposure of spine & resection of vrtbrl sgmt(s) (incl body & posterior elements); 3+ sgmts

 

22830

Exploration of spinal fusion

+

22840

Posterior non-segmntl instrumntn (e.g., Harrington rod techn, pedicle fixatn across 1 intrspc, atlantoaxial transarticular screw fixatn, sublaminar wiring at C1, facet screw fixatn)

+

22841

Intrnl spinal fixatn by wiring of spinous processes

+

22842

Posterior segmntl instrmntn (e.g., pedicle fixatn, dual rods w/mult hooks & sublaminar wires); 3-6 vrtbrl sgmts

+

22843

Posterior segmntl instrmntn (e.g., pedicle fixatn, dual rods w/mult hooks & sublaminar wires); 7-12 vrtbrl sgmts

+

22844

Posterior segmntl instrmntn (e.g., pedicle fixation, dual rods w/mult hooks & sublaminar wires); 13+ vrtbrl sgmts

+

22845

Anterior instrmntn; 2-3 vrtbrl sgmts

+

22846

Anterior instrmntn; 4-7 vrtbrl sgmts

+

22847

Anterior instrmntn; 8+ vrtbrl sgmts

+

22848

Pelvic fixatn (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum

 

22849

Reinsertion of spinal fixation device

 

22850

Rmvl of posterior nonsgmtl instrumentation (e.g., Harrington rod)

 

22852

Rmvl of posterior sgmtl instrumentation

 

22855

22864

22865

Removal of anterior instrumentation

Rmvl of total disc arthroplasty (artificial disc), ant approach, single interspace; cervical;

Rmvl of total disc arthroplasty (artificial disc), ant approach, single interspace; lumbar

 

22867

Insertn of interlaminar/interspinous process stabilization/distraction dvc, w/out fusn, incl img guid, when perfor, w/open dcmprsn, lumbar; sgl lvl

+

22868

    2nd level

 

22869

Insertn of interlaminar/interspinous process stabilization/distraction dvc, w/out open dcmprsn or fusn, incl img guid when perf, lumbar; sgl lvl

+

22870

   2nd level

 

27080

Coccygectomy, primary

 

27096

Inj proc for sacroiliac jt, arthrography &/or anesthetic/steroid [up to 2 inj to diagnose & achieve therapeutic effect, no repeats > once every 7 days, no addtl inj > once every 2 mths or beyond 12 mths]

 

27279

Arthrodesis, sacroiliac jt, percut or minimally invasv (indir visualizatn), w/img guid, incl obtaining bone graft when perf, & plcmt of transfixing dvc

 

27280

Arthrodesis, open, sacroiliac jt, incl obtaining bone graft, incl instrumentation, when perf

 

62263

Percut lysis of epidural adhesions using solution inj (e.g., hypertonic saline, enzyme) or mechanical means (eg, catheter) incl radiologic localization (incl contrast when admin), mult adhesiolysis sessions; 2+ days

 

62264

Percut lysis of epidural adhesions using solution inj (e.g., hypertonic saline, enzyme) or mechanical means (eg, catheter) incl radiologic localization (incl contrast when admin), mult adhesiolysis sessions; 1 day

 

62267

Percut aspiration w/in the nucleus pulposus, intervrtbrl disc, or paravrtbrl tissue for diag purposes

 

62280

Inj/infsn of neurolytic subst, w/ or w/out other therap subst; subarachnoid ultrasonic guid for needle plcmt, img supv & interpr [not covd for chemical ablation of facet jts]

 

62281

Inj/infsn of neurolytic subst, w/ or w/out other therap subst; epidural, cervical or thoracic [not cvd for chemical ablation (incl but not ltd to alcohol, phenol or sodium morrhuate) of facet jts]

 

62282

Inj/infsn of neurolytic subst, w/ or w/out other therap subst; epidural, lumbar, sacral (caudal) [not cvd for chemical ablation (incl but not ltd to alcohol, phenol or sodium morrhuate) of facet jts]

 

62287

Dcmprsn proc, percut, of nucleus pulposus of intervrtbrl disc, any method, sgl or mltpl lvls, lumbar (e.g., manual or automated percut discectomy, percut laser discectomy)

 

62292

Inj proc for chemonucleolysis, inclg discography, intervrtbrl disc, sgl or mult lvls, lumbar

 

62302

Myelography via lumbar inj, incl radiological supv & interpret; cervical

 

62303

Myelography via lumbar inj, incl radiological supv & interpret; thoracic

 

62304

Myelography via lumbar inj, incl radiological supv & interpret; lumbosacral

 

62305

Myelography via lumbar inj, incl radiological supv & interpret; 2+ regions

 

62320

Inj, of diag or therap subst, not incl neurolytic subst, incl needle or catheter plcmt, interlaminar epidural or subarachnoid, cervical or thoracic; w/o img guid

 

62321

Inj, of diag or therap subst, not incl neurolytic subst, incl needle or catheter plcmt, interlaminar epidural or subarachnoid, cervical or thoracic; w/img guid (ie, fluoroscopy or CT)

 

62322

Inj, of diag or therap subst, not incl neurolytic subst, incl needle or catheter plcmt, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); w/o img guid

 

62323

Inj, of diag or therap subst, not incl neurolytic subst, incl needle or catheter plcmt, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); w/img guid (ie, fluoroscopy or CT)

 

62324

Inj, incl indwelling catheter plcmt, contin infsn or intermittent bolus, of diag or therap subst, not incl neurolytic subst, interlaminar epidural or subarachnoid, cervical or thoracic; w/o img guid

 

62325

Inj, incl indwelling catheter plcmt, contin infsn or intermittent bolus, of diag or therap subst, not incl neurolytic subst, interlaminar epidural or subarachnoid, cervical or thoracic; w/img guid (ie, fluoroscopy or CT)

 

62326

Inj, incl indwelling catheter plcmt, contin infsn or intermittent bolus, of diag or therap subst, not incl neurolytic subst, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); w/o img guid

 

62327

Inj, incl indwell catheter plcmt, contin infsn or intermittent bolus, of diag or therap subst, not incl neurolytic subst, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); w/img guid (ie, fluoroscopy or CT)

 

62380

Endoscopic dcmprsn of spinal cord, nerve root(s), incl laminotomy, prtl facetectomy, foraminotomy, discectomy &/or excsn of herniated intervrtbrl disc, 1 intrspc, lumbar

+

63035

Laminotomy (hemilaminectomy), w/dcmprsn of nerve root(s), incl prtl facetectomy, foraminotomy &/or excision of herniated intervrtbrl disc; ea addtl intrspc, cervical or lumbar

+

63043

    ea addtl cervical intrspc

+

63044

    ea addtl lumbar intrspc

+

63048

    ea addtl sgmt, cervical, thoracic, or lumbar

+

63057

Transpedicular approach w/dcmprsn of spinal cord, equina &/or nerve(s) (eg, herniated intrvrtbrl disc), sgl sgmt; ea addtl sgmt, thoracic or lumbar

+

63066

Costovertebral approach w/dcmprsn of spinal cord or nerve root(s), (e.g., herniated intervertebral disk), thoracic; ea addtl sgmt

+

63076

    cervical, ea addtl intrspc

+

63078

    ea addtl intrspc

+

63082

    cervical, ea addtl sgmt

+

63086

Vrtbrl corpectomy (vrtbrl body resection), prtl or cmplt, trnsthoracic approach w/dcmprsn of spinal cord and/or nerve root(s); thoracic, ea addtl sgmt

+

63088

Vrtbrl corpectomy (vrtbrl body resection), prtl or cmplt, combined thoracolumbar approach w/dcmprsn of spinal cord, cauda equina or nerve root(s), lwr thoracic or lumbar; ea addtl sgmt

+

63091

Vrtbrl corpectomy (Vrtbrl body resection), prtl or cmplt, transperitoneal or retroperitoneal approach w/dcmprsn of spinal cord, cauda equina or nerve root(s), lwr thoracic, lumbar, or sacral; ea addtl sgmt

+

63103

Vrtbrl corpectomy (Vrtbrl body resection), prtl or cmplt, lateral extracavitary approach w/dcmprsn of spinal cord &/or nerve root(s) (e.g., for tumor or retropulsed bone fragments); thoracic or lumbar, ea addtl sgmt

+

63308

Vrtbrl corpectomy (Vrtbrl body resection), prtl or cmplt, for excsn of intrspnl lesion, sgl sgmt; ea addtl sgmt

 

64420

INJECTION AA&/STRD INTERCOSTAL NRV SINGLE LVL (Revised code eff 01/01/2020)

 

64421

INJECTION AA&/STRD INTERCOSTAL NRV EA ADDL LVL  (Revised code eff 01/01/2020)

 

64450

INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH  (Revised code eff 01/01/2020)

 

64479

Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level (code revised eff 01-01-2021)

+

64480

    ea addtl lvl

 

64483

Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (code revised eff 01-01-2021)

+

64484

    ea addtl lvl

 

64490

Inj, diagnostic or therap agt, paravrtbrl facet (zygapophyseal) jt (or nerves innervating that joint) w/img guid (fluoroscopy or CT), cervical or thoracic; sgl lvl

+

64491

    2nd lvl

+

64492

    3rd & any addtl lvl(s)

 

64493

Inj, diag or therap agt, paravrtbrl facet (zygapophyseal) jt (or nerves innervating that joint) w/img guid (fluoroscopy or CT), lumbar or sacral; sgl lvl

+

64494

    2nd lvl

+

64495

    3rd & any addtl lvl(s)

 

64633

Destruction by neurolytic agent, paravrtbrl facet jt nerve(s), w/img guid (fluoroscopy or CT); cervical or thoracic, sgl facet jt [not cvd for cooled radiofrequency ablation]

+

64634

    cervical or thoracic, ea addtl facet joint  [not cvd for cooled radiofrequency ablation]

 

64635

    lumbar or sacral, sgl facet joint [not cvd for cooled radiofrequency ablation]

+

64636

    lumbar or sacral, ea addtl facet joint [not cvd for cooled radiofrequency ablation]

 

64712

Inj, anesthetic agent; other peripheral nerve or branch [coccygeal ganglion (ganglion impar) block]

+

69990

Operating microscope

 

0200T

Percut sacral augmentation (sacroplasty), unilat inj(s), incl the use of a balloon or mechanical device, when used, 1+ needles, incl img guid & bone biopsy, when perf

 

0201T

Percut sacral augmentation (sacroplasty), bilat inj, incl the use of a balloon or mechan dvc, when used, 2+ needles, incl img guid & bone biopsy, when perf

 

0202T

Posterior vrtbrl joint(s) arthroplasty (e.g., facet joint[s] rplcmt) incl facetectomy, laminectomy, foraminotomy & vrtbrl column fixtn, w/ or w/out inj of bone cement, incl fluoroscopy, sgl lvl, lumbar spine

 

0213T

Inj, diag or therap agt, paravrtbrl facet (zygapophyseal) jt (or nerves innervating that joint) w/ultrasnd guid, cervical or thoracic; sgl lvl

+

0214T

    2nd lvl

+

0215T

    3rd & any addtl lvls

 

0216T

Inj, diag or therap agt, paravrtbrl facet (zygapophyseal) jt (or nerves innervating that joint) w/ultrasnd guid, lumbar or sacral; sgl lvl

+

0217T

    2nd lvl

+

0218T

    3rd & any addtl lvls

 

0219T

Plcmt of a posterior intrafacet implant(s), unilat or bilat, incl img & plcmt of bone graft(s) or synthetic dvc(s), sgl lvl; cervical

 

0220T

    thoracic

 

0221T

    lumbar

+

0222T

    ea addtl vrtbrl sgmt

 

0274T

Percutaneous laminotomy/laminectomy (intralaminar approach) for decmprsn of neural elements, any method under indir img guid, w/ or w/o the use of an endoscope, sgl or mltpl lvls, unilat or bilat; cervical or thoracic

 

0275T

    lumbar

 

0481T

Inj, autologous white blood cell concentrate (autologous protein solution), any site, incl img guid, harvesting & prep, when perf

 

C2614

Probe, percut lumbar discectomy

 

C9752

Destruction of intraosseous basivrtbrl nerve, first 2 vertebral bodies, incl img guid (e.g., fluoroscopy), lumbar/sacrum

 

C9753

Destruction of intraosseous basivrtbrl nerve, ea addtl vrtbrl body, incl img guid (e.g., fluoroscopy), lumbar/sacrum

 

G0259

Inj proc for sacroiliac joint; arthrography

 

G0260

Inj proc for sacroiliac jt; prvsn of anesthetic, steroid &/or other therapeutic agt, w/ or w/out arthrography

 

G0276

Blinded proc for lumbar stenosis, percut img-hyphenguided lumbar dcmprsn (PILD) or placebo-hyphencontrol, perf in an aprvd cvg w/evidence dvlpmt (CED) clinical trial

 

S2348

Decmprsn proc, percut, of nucleus pulposus of intervrtbrl disc, using radiofreq energy, sgl or mltpl lvls, lumbar

 

S2350

Discectomy, anterior, w/decmprsn of spinal cord &/or nerve root(s), incl osteophytectomy; lumbar, sgl intrspc

+

S2351

Discectomy, anterior, w/decmprsn of spinal cord &/or nerve root(s), incl osteophytectomy; lumbar, ea addtl intrspc

 

C9757

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and excision of herniated intervertebral disc, and repair of annular defect with implantation of bone anchored annular closure device, including annular defect measurement, alignment and sizing assessment, and image guidance; 1 interspace, lumbar

 

62328

DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT

 

62329

THERAPEUTIC SPINAL PNXR DRAINAGE CSF W/FLUOR/CT

 

64451

INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG

 

64454

INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG


Limits

Arthrodesis of the sacroiliac joint (27279, 27280) is considered experimental/investigational for low back pain and is not covered.  According to the Hayes review of the literature, research supporting efficacy for low back pain is of low quality.


Reference

1.    Abbott AD, Tyni-Lenne R, Hedlund R. Early rehabilitation targeting cognition, behavior, and motor function after lumbar fusion: a randomized controlled trial. Spine 2010; 35(8):848-57. DOI: 10.1097/BRS.0b013e3181d1049f.  View abstract...

2.    Rector C. Transcultural nursing in the community. In: Allender JA, Rector C, Warner KD, editors. Community Health Nursing Promoting and Protecting the Public`s Health. 7th ed. Philadelphia, PA: Wolters Kluwer Health; 2010:91-120.

3.    Lumbar spine surgery. A guide to preoperative and postoperative patient care. AANN Clinical Practice Guideline Series [Internet] American Association of Neuroscience Nurses. 2009 Accessed at: http://www.aann.org/pubs/guidelines.html. [Created 2004; accessed 2011 Sep 7].

4.    Musculoskeletal care modalities. In: Smeltzer SC, Bare BG, Hinkle JL, Cheever KH, editors. Brunner & Suddarth`s Textbook of Medical-Surgical Nursing. 12th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:2023-51

5.    Ready to go? Planning the discharge and the transfer of patients from hospital and intermediate care [Internet] Department of Health. 2010 Mar 12 Accessed at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/index.htm. [Accessed 2011 Sep 14].

6.    Corbett CF, Setter SM, Daratha KB, Neumiller JJ, Wood LD. Nurse identified hospital to home medication discrepancies: implications for improving transitional care. Geriatric Nursing 2010 May-Jun; 31(3):188-96. DOI: 10.1016/j.gerinurse.2010.03.006. View abstract...

7.    Greenwald JL, et al. Making inpatient medication reconciliation patient centered, clinically relevant, and implementable: a consensus statement on key principles and necessary first steps. Joint Commission Journal on Quality and Patient Safety 2010; 36(11):504-13, 481. View abstract...

8.    Feldman PH, et al. Medication management: evidence brief. Center for Home Care Policy & Research. Home Healthcare Nurse 2009; 27(6):379-86. DOI: 10.1097/01.NHH.0000356831.11843.16.

9.    Young B. Medication reconciliation matters. Medsurg Nursing 2008; 17(5):332-6. .  View abstract...

10.   Kerridge-Weeks, Davies. Outcome and rehabilitation of a series of patients undergoing elective lumbar spine surgery: implications for clinicians. Back Care Journal 2010 ;( autumn):7-12.

11.   Freeman BL III. Scoliosis and kyphosis. In: Canale ST, Beaty JH, editors. Campbell`s Operative Orthopedics. 11th ed. Philadelphia, PA: Mosby Elsevier; 2008:1921-2158

12.   Zaiontz RG, Lewis SL. Inflammation and wound healing. In: Lewis SL, Dirksen SR, Heitkemper MM, Bucher L, Camera IM, editors. Medical Surgical Nursing: Assessment and Management of Clinical Problems. 8th ed. St. Louis, MO: Elsevier Mosby; 2011:186-205.

13.   Delitto A, George SZ, et al. Low back pain. J Orthop Sports Phys Ther 2012 Apr; 42(4):A1-A57.

14.   Chou R, Qaseem A, et al. Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2; 147(7):478-91.

15.   Indrakanti SS, Weber MH, Takemoto SK, et al. Value-based care in the management of spinal disorders: a systematic review of cost-utility analysis. Clin Orthop Relat Res. 2012 Apr; 470(4):1106-23.

16.   Washington State Department of Labor and Industries.  Surgical guideline for lumbar fusion (arthrodesis).  Office of the medical director, 1 November 2009

Addendum: 

1)    Effective 09/01/2017: Clarification that sacroiliac fusion for low back pain is experimental/investigational.

2)    Effective 01/01/2018: Added new CPT code 20939.

3)    Effective 06/01/2019: Codes update. 0213T-0215T paravertebral facet joint injections are covered without prior authorization. CPT 0219T-0222T and 0201T – 0212T sacroplasty,  Posterior vertebral joint(s) arthroplasty, 0219T-0222T, placement of posterior intrafacet implant, 0481T injections of autologous white blood cell concentrate, and 0274T – 0275T Percutaneous laminotomy/laminectomy are considered Experimental and Investigational and are therefore not covered

4)    Effective 12/01/2019:  Added codes 22552, 22610, 22864 and 22865 to the claims statement and medical policy statement to reflect a PA requirement as well as added a description to the codes.  I also added codes 22610, 22864 and 22865 in the search box and took out the code ranges, listing all the codes separately.

5)    Effective 01/01/2020: Code updates – Added new codes C9757, 62328, 62329, 64451 and 64454 to the search box as well as added descriptions eff 01/01/2020.  Added new code C9757 to the list requiring preauthorization. Deleted code 20926 eff 01/01/2020.  Revised codes 64420, 64421 and 64450 were updated eff 01/01/2020.

6)    Effective 05/01/2020: Spinal injections performed by neurosurgeons and orthopedic surgeons do not require prior authorization. Medical necessity criteria added for Lumbar and thoracic surgeries. Defined conservative management and criteria for waiver of conservative management. Any disagreement with official reports of advanced imaging studies (CT, MRI and myelograms) requires documentation by surgeon in the medical records. Updated CPT code listing to include parent codes.

7)    Effective 10/01/2020: Interspinous/interlaminar process stabilization/spacer device and its removal are considered experimental and investigational.

8)    Effective 05/01/2020: Spinal injections performed by Physical Medicine and Rehabilitation (PM&R) physicians do not require prior authorization.

9)    Updated revised codes Eff 01-01-2021: 64479 and 64483


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
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