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. 1 2018 r2.16.2018connecticare Utilization Review Matrix- Spine Surgery (002).doc
Inpatient and Outpatient: Non-Emergency Spine Surgery Implantable Infusion Pump Insertion LUMBAR SPINE SURGERY 63030 Lumbar Microdiscectomy 62380, 63030, +63035 63047 Lumbar Decompression 62380, 63030, +63035, 63005, 63012, 63017, 63042, +63044, 63047, +63048, 63056, +63057 22612 Lumbar Fusion Single Level** 22533, 22558, 22612, 22630, 22633 22614 Lumbar Fusion Multiple Levels** 22533, 22558, 22612, 22630, 22633, +22534, +22585, +22614, +22632, +22634 22857 Lumbar Artificial Disc - Single Level Note: Benefit Exclusion for Exchange Plans 22857, 22862, 22865 22551 CERVICAL SPINE SURGERY Anterior Cervical Decompression with Fusion (ACDF) Single Level** 22548, 22551, 22554 22552 63045 22600 22595 22856 22858 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, +22552, +22585 63001, 63015, 63020,+63035, 63040, +63043, 63045, +63048, 63050, 63051 22590, 22595, 22600 22590, 22595, 22600, +22614 22856, 22861, 22864 22858, 0098T, 0095T 2 2018 r2.16.2018connecticare Utilization Review Matrix- Spine Surgery (002).doc-r2.16.2018
63075 CERVICAL SPINE SURGERY Cervical Anterior Decompression (without fusion) 63075, +63076 DEFORMITY SURGERY, THORACIC SURGERY & OTHER SPINE SURGERY 22802 Deformity Surgery (Adult)** (Pediatric Deformity: NIA requires registration of all pediatric deformity surgeries performed on patients who are age 17 years of age.) 22610 Thoracic Surgery (Non-Deformity)** 63267 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, 22226 22532, 22534, 22556, 22585, 22610, 22614, 22830, 63003, 63016, 63046, 63048, 63055, 63057, 63064, 63066, 63077, 63078 63265, 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, 22534 IMPLANTABLE INFUSION PUMP INSERTION 62362 Implantable Infusion Pump Insertion 62350, 62351, 62355, 62360, 62361, 62362 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 3 2018 r2.16.2018connecticare Utilization Review Matrix- Spine Surgery (002).doc-r2.16.2018
authorization may be requested to review extenuating or unique clinical circumstances on a case-by-case basis. Representative Procedure Groupings 22858 0163T 62264 62287 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, 62264 62287, 0274T, 0275T 22526 Percutaneous Thermal Intra-Discal Procedures (including IDET) 22526, 22527, 22899 22586 Pre-Sacral/Axial Interbody Fusion 22586, 0195T, 0196T, 22899 27280 Sacroiliac Joint Arthrodesis (percutaneous or open) 27279, 27280 22867 Interspinous Spacer Device (X-Stop) 22867, 22868, 22869, 22870, C1821 0202T Total Facet Arthroplasty 0202T 0219T Posterior Intra-Facet Implants 0219T, 0220T, 0221T, 0222T M0076 Prolotherapy M0076 4 2018 r2.16.2018connecticare Utilization Review Matrix- Spine Surgery (002).doc-r2.16.2018
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. 5 2018 r2.16.2018connecticare Utilization Review Matrix- Spine Surgery (002).doc-r2.16.2018