ConnectiCare Commercial & Exchange Members Utilization Review Matrix 2018 Spine Surgery, Implantable Infusion Pump Insertion & Other Spine Procedures

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1 ConnectiCare Commercial & Exchange Members Utilization Review Matrix 2018 Spine Surgery, Implantable Infusion Pump Insertion & Other Spine Procedures The matrix below contains all of the CPT-4 codes for which Magellan Healthcare 1 authorizes on behalf of its clients. This matrix is designed to assist in the resolution of claims adjudication and claims questions related to those procedures authorized by Magellan Healthcare. The is meant to outline that if a given procedure is authorized, that any of the listed procedures codes could be submitted on a claim representing that service. This assumes that the member is eligible at the time of the service, that appropriate rebundling rules are applied, that the claim includes an appropriate diagnosis code for the CPT code and that the service is performed within the validity period. If a family of CPT codes is not listed in this matrix, an exact match is required between the authorized CPT code and the billed CPT code. If the exact match does not occur, the charge should be adjudicated accordingly. *Please note: Pediatric deformity spine surgery for patients under 18 will require preregistration but will not be subject to preauthorization review including submission of documentation. NIA will not manage the preauthorization process for emergency spine surgery cases when the patients are admitted through the emergency room or spine surgery procedures not listed above. Facilities must continue to follow ConnectiCare s current notification requirements for urgent/emergent hospital admissions and elective surgery based on a member s benefit and coverage requirements. Inpatient admissions will continue to be subject to concurrent review by ConnectiCare. 1 National Imaging Associates, Inc. is a subsidiary of Magellan Healthcare, Inc r connecticare Utilization Review Matrix- Spine Surgery (002).doc

2 Inpatient and Outpatient: Non-Emergency Spine Surgery Implantable Infusion Pump Insertion LUMBAR SPINE SURGERY Lumbar Microdiscectomy 62380, 63030, Lumbar Decompression 62380, 63030, , 63005, 63012, 63017, 63042, , 63047, , 63056, Lumbar Fusion Single Level** 22533, 22558, 22612, 22630, Lumbar Fusion Multiple Levels** 22533, 22558, 22612, 22630, 22633, , , , , Lumbar Artificial Disc - Single Level Note: Benefit Exclusion for Exchange Plans 22857, 22862, CERVICAL SPINE SURGERY Anterior Cervical Decompression with Fusion (ACDF) Single Level** 22548, 22551, Anterior Cervical Decompression with Fusion (ACDF) Multiple Level** Cervical Posterior Decompression (without fusion) Cervical Posterior Decompression with Fusion Single Level** Cervical Posterior Decompression with Fusion Multiple Levels** Cervical Artificial Disc - Single Level Note: Benefit Exclusion for Exchange Plans Cervical Artificial Disc - Two Levels Note: Benefit Exclusion for Exchange Plans **0375T is not a covered service and is not reimbursable 22548, 22551, 22554, , , 63015, 63020,+63035, 63040, , 63045, , 63050, , 22595, , 22595, 22600, , 22861, , 0098T, 0095T r connecticare Utilization Review Matrix- Spine Surgery (002).doc-r

3 63075 CERVICAL SPINE SURGERY Cervical Anterior Decompression (without fusion) 63075, DEFORMITY SURGERY, THORACIC SURGERY & OTHER SPINE SURGERY Deformity Surgery (Adult)** (Pediatric Deformity: NIA requires registration of all pediatric deformity surgeries performed on patients who are age 17 years of age.) Thoracic Surgery (Non-Deformity)** Spine Surgery Other: Neoplasm, Lesion, Infection (All Regions)** 22800, 22802, 22804, 22808, 22810, 22812, 22830, 22630, 22632, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, , 22534, 22556, 22585, 22610, 22614, 22830, 63003, 63016, 63046, 63048, 63055, 63057, 63064, 63066, 63077, , 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22554, 22556, 22558, 22585, 22532, 22533, IMPLANTABLE INFUSION PUMP INSERTION Implantable Infusion Pump Insertion 62350, 62351, 62355, 62360, 62361, Other Spine Procedures or Devices- No or Limited Evidence of Effectiveness nes ConnectiCare will not provide reimbursement for the following CPT codes as there is no or limited evidence these procedures are effective. NIA prior r connecticare Utilization Review Matrix- Spine Surgery (002).doc-r

4 authorization may be requested to review extenuating or unique clinical circumstances on a case-by-case basis. Representative Procedure Groupings T Cervical Artificial Disc - Two Levels Note: Benefit Exclusion for Exchange Plans. Medical Necessity Review for Non-Exchange Plans **0375T is not a covered service and is not reimbursable Lumbar Artificial Disc - Multiple Levels Epidural Lysis of Adhesions (Racz procedure) Note: Benefit Exclusion for Exchange Plans. Medical Necessity Review for Medicare Plans Minimally Invasive Decompression (including MILD) 22858, 0098T, 0095T 0163T, 0164T, 0165T 62263, , 0274T, 0275T Percutaneous Thermal Intra-Discal Procedures (including IDET) 22526, 22527, Pre-Sacral/Axial Interbody Fusion 22586, 0195T, 0196T, Sacroiliac Joint Arthrodesis (percutaneous or open) 27279, Interspinous Spacer Device (X-Stop) 22867, 22868, 22869, 22870, C T Total Facet Arthroplasty 0202T 0219T Posterior Intra-Facet Implants 0219T, 0220T, 0221T, 0222T M0076 Prolotherapy M r connecticare Utilization Review Matrix- Spine Surgery (002).doc-r

5 Code Notes: + codes (add-on codes) do not require separate authorization* and are to be used in conjunction with approved primary code for the service rendered. *There are two exceptions to this add-on comment for the following: o Multiple level fusion add-on codes require an authorization prior to payment; o Multiple level artificial disc add-on codes should not be assumed payable with a single level artificial disc authorization. ** Decompression procedures, instrumentation, and bone grafts do not require a separate authorization when done in combination with a fusion. These are assumed as part of the fusion authorization. Spine surgeries typically have more than one CPT associated with each case and often times a decompression is performed during the fusion surgery both will be billed. Multiple units may be required to accommodate the surgeon, cosurgeon and outpatient facility billing where applicable r connecticare Utilization Review Matrix- Spine Surgery (002).doc-r

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