SPINAL SURGERY Codes Requiring Prior Authorization Effective 07/15/18
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1 SPINAL SURGERY Codes Requiring Prior Authorization Effective 07/15/18 PROC_NBR DESCRIPTION 0095T RMVL ARTIFIC DISC ADDL CRVCL 0098T REV ARTIFIC DISC ADDL 0163T LUMB ARTIF DISKECTOMY ADDL 0164T REMOVE LUMB ARTIF DISC ADDL 0165T REVISE LUMB ARTIF DISC ADDL 0195T PRESCRL FUSE W/O INSTR L5/S1 0196T PRESCRL FUSE W/O INSTR L4/L5 0200T PERQ SACRAL AUGMT UNILAT INJ 0201T PERQ SACRAL AUGMT BILAT INJ 0202T POST VERT ARTHRPLST 1 LUMBAR 0205T INIRS EACH VESSEL ADD-ON 0207T CLEAR EYELID GLAND W/HEAT 0219T PLMT POST FACET IMPLT CERV 0220T PLMT POST FACET IMPLT THOR 0221T PLMT POST FACET IMPLT LUMB 0222T PLMT POST FACET IMPLT ADDL 0274T PERQ LAMOT/LAM CRV/THRC 0275T PERQ LAMOT/LAM LUMBAR 0309T PRESCRL FUSE W/ INSTR L4/L BONE MARROW ASPIR BONE GRFG REMOVE PART THORAX VERTEBRA REMOVE PART LUMBAR VERTEBRA REMOVE EXTRA SPINE SEGMENT REMOVE PART OF NECK VERTEBRA REMOVE PART THORAX VERTEBRA REMOVE PART LUMBAR VERTEBRA REMOVE EXTRA SPINE SEGMENT INCIS SPINE 3 COLUMN THORAC INCIS SPINE 3 COLUMN LUMBAR INCIS SPINE 3 COLUMN ADL SEG INCIS 1 VERTEBRAL SEG CERV INCIS 1 VERTEBRAL SEG THORAC INCIS 1 VERTEBRAL SEG LUMBAR
2 22216 INCIS ADDL SPINE SEGMENT INCIS W/DISCECTOMY CERVICAL INCIS W/DISCECTOMY THORACIC INCIS W/DISCECTOMY LUMBAR REVISE EXTRA SPINE SEGMENT PERQ CERVICOTHORACIC INJECT PERQ LUMBOSACRAL INJECTION VERTEBROPLASTY ADDL INJECT PERQ VERTEBRAL AUGMENTATION PERQ VERTEBRAL AUGMENTATION PERQ VERTEBRAL AUGMENTATION LAT THORAX SPINE FUSION LAT LUMBAR SPINE FUSION LAT THOR/LUMB ADDL SEG NECK SPINE FUSION NECK SPINE FUSE&REMOV BEL C ADDL NECK SPINE FUSION NECK SPINE FUSION THORAX SPINE FUSION LUMBAR SPINE FUSION ADDITIONAL SPINAL FUSION PRESCRL FUSE W/ INSTR L5-S SPINE & SKULL SPINAL FUSION NECK SPINAL FUSION NECK SPINE FUSION THORAX SPINE FUSION LUMBAR SPINE FUSION SPINE FUSION EXTRA SEGMENT LUMBAR SPINE FUSION SPINE FUSION EXTRA SEGMENT LUMBAR SPINE FUSION COMBINED SPINE FUSION EXTRA SEGMENT POST FUSION </6 VERT SEG POST FUSION 7-12 VERT SEG POST FUSION 13/> VERT SEG ANT FUSION 2-3 VERT SEG
3 22810 ANT FUSION 4-7 VERT SEG ANT FUSION 8/> VERT SEG KYPHECTOMY 1-2 SEGMENTS KYPHECTOMY 3 OR MORE EXPLORATION OF SPINAL FUSION INSERT SPINE FIXATION DEVICE INSERT SPINE FIXATION DEVICE INSERT SPINE FIXATION DEVICE INSERT SPINE FIXATION DEVICE INSERT SPINE FIXATION DEVICE INSERT SPINE FIXATION DEVICE INSERT SPINE FIXATION DEVICE INSERT SPINE FIXATION DEVICE INSERT PELV FIXATION DEVICE REINSERT SPINAL FIXATION REMOVE SPINE FIXATION DEVICE REMOVE SPINE FIXATION DEVICE INSJ BIOMCHN DEV INTERVERTEBRAL DSC SPC W/ARTHRD INSJ BIOMCHN DEV VRT CORPECTOMY DEFECT W/ARTHRD REMOVE SPINE FIXATION DEVICE CERV ARTIFIC DISKECTOMY LUMBAR ARTIF DISKECTOMY SECOND LEVEL CER DISKECTOMY INSJ BIOMCHN DEV NTRVRT DISC SPACE W/O ARTHRD REVISE CERV ARTIFIC DISC REVISE LUMBAR ARTIF DISC REMOVE CERV ARTIF DISC REMOVE LUMB ARTIF DISC INSJ STABLJ DEV W/DCMPRN LUMBAR SINGLE LEVEL INSJ STABLJ DEV W/DCMPRN LUMBAR SECOND LEVEL INSJ STABLJ DEV W/O DCMPRN LUMBAR SINGLE LEVEL INSJ STABLJ DEV W/O DCMPRN LUMBAR SECOND LEVEL ARTHRODESIS SACROILIAC JOINT PERCUTANEOUS DISKECTOMY NDSC DCMPRN SPINAL CORD 1 W/LAMOT NTRSPC LUMBAR REMOVE SPINE LAMINA 1/2 CRVL
4 63003 REMOVE SPINE LAMINA 1/2 THRC REMOVE SPINE LAMINA 1/2 LMBR REMOVE SPINE LAMINA 1/2 SCRL REMOVE LAMINA/FACETS LUMBAR REMOVE SPINE LAMINA >2 CRVCL REMOVE SPINE LAMINA >2 THRC REMOVE SPINE LAMINA >2 LMBR NECK SPINE DISK SURGERY LOW BACK DISK SURGERY SPINAL DISK SURGERY ADD-ON LAMINOTOMY SINGLE CERVICAL LAMINOTOMY SINGLE LUMBAR LAMINOTOMY ADDL CERVICAL LAMINOTOMY ADDL LUMBAR REMOVE SPINE LAMINA 1 CRVL REMOVE SPINE LAMINA 1 THRC REMOVE SPINE LAMINA 1 LMBR REMOVE SPINAL LAMINA ADD-ON CERVICAL LAMINOPLSTY 2/> SEG C-LAMINOPLASTY W/GRAFT/PLATE DECOMPRESS SPINAL CORD THRC DECOMPRESS SPINAL CORD LMBR DECOMPRESS SPINE CORD ADD-ON DECOMPRESS SPINAL CORD THRC DECOMPRESS SPINE CORD ADD-ON NECK SPINE DISK SURGERY NECK SPINE DISK SURGERY SPINE DISK SURGERY THORAX SPINE DISK SURGERY THORAX REMOVE VERT BODY DCMPRN CRVL REMOVE VERTEBRAL BODY ADD-ON REMOVE VERT BODY DCMPRN THRC REMOVE VERTEBRAL BODY ADD-ON REMOV VERTBR DCMPRN THRCLMBR REMOVE VERTEBRAL BODY ADD-ON REMOVE VERT BODY DCMPRN LMBR
5 63091 REMOVE VERTEBRAL BODY ADD-ON REMOVE VERT BODY DCMPRN THRC REMOVE VERT BODY DCMPRN LMBR REMOVE VERTEBRAL BODY ADD-ON INCISE SPINAL CORD TRACT(S) DRAINAGE OF SPINAL CYST DRAINAGE OF SPINAL CYST REVISE SPINAL CORD LIGAMENTS REVISE SPINAL CORD LIGAMENTS INCISE SPINE NRV HALF SEGMNT INCISE SPINE NRV >2 SEGMNTS INCISE SPINE ACCESSORY NERVE INCISE SPINE & CORD CERVICAL INCISE SPINE & CORD THORACIC INCISE SPINE&CORD 2 TRX CRVL INCISE SPINE&CORD 2 TRX THRC INCISE SPIN&CORD 2 STGS CRVL INCISE SPIN&CORD 2 STGS THRC RELEASE SPINAL CORD LUMBAR REVISE SPINAL CORD VSLS CRVL REVISE SPINAL CORD VSLS THRC REVISE SPINE CORD VSL THRLMB EXCISE INTRASPINL LESION CRV EXCISE INTRSPINL LESION THRC EXCISE INTRSPINL LESION LMBR EXCISE INTRSPINL LESION SCRL EXCISE INTRSPINL LESION CRVL EXCISE INTRSPINL LESION THRC EXCISE INTRSPINL LESION LMBR EXCISE INTRSPINL LESION SCRL BX/EXC XDRL SPINE LESN CRVL BX/EXC XDRL SPINE LESN THRC BX/EXC XDRL SPINE LESN LMBR BX/EXC XDRL SPINE LESN SCRL BX/EXC IDRL SPINE LESN CRVL BX/EXC IDRL SPINE LESN THRC
6 63282 BX/EXC IDRL SPINE LESN LMBR BX/EXC IDRL SPINE LESN SCRL BX/EXC IDRL IMED LESN CERVL BX/EXC IDRL IMED LESN THRC BX/EXC IDRL IMED LESN THRLMB BX/EXC XDRL/IDRL LSN ANY LVL REPAIR LAMINECTOMY DEFECT REMOVE VERT XDRL BODY CRVCL REMOVE VERT XDRL BODY THRC REMOVE VERT XDRL BODY THRLMB REMOV VERT XDRL BDY LMBR/SAC REMOVE VERT IDRL BODY CRVCL REMOVE VERT IDRL BODY THRC REMOV VERT IDRL BDY THRCLMBR REMOV VERT IDRL BDY LMBR/SAC REMOVE VERTEBRAL BODY ADD-ON G0276 PILD/PLACEBO CONTROL CLIN TR S2348 DECOMP PERQ DISC RF 1/MX LUMB S2350 DISKECT ANT-OSTEOPHYT;LUMB 1 INTRSP S2351 DSKCT ANT-OSTEOPHYT;LUMB ADD INTRSP
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