August 2010
Spinal surgery criteria change
Note from the editor (5/1/11): CPT 22551 is a new 2011 CPT code and has been added to our Group and Individual Products medical pre-authorization list effective May 1, 2011. According to CPT guidelines, do not report CPT 22554 in conjunction with CPT 63075, even if performed by separate providers. To report anterior cervical disectomy and interbody fusion at the same level during the same session, use the new 2011 CPT 22551.
Effective November 1 the following spinal procedure codes will require pre-authorization.
CPT or HCPCS code |
Brief description |
Pre-authorization required |
|
Group and Individual |
Asuris TruAdvantage |
||
22554 22600 |
Cervical Fusion | Yes | Yes |
22558 22612 22630 |
Lumbar Fusion | Yes | Yes |
0171T 0172T |
Spinal Distraction Device | No (Investigational, Non-covered) |
Yes |
22861 |
Cervical Artificial Disk Replacement (ADR) |
No (Investigational, Non-covered) |
Yes |
0095T |
Cervical ADR |
No (Investigational, Non-covered) |
Yes |
22865 |
Lumbar ADR |
No (Investigational, Non-covered) |
Yes |
22520 22521 22522 22523 22524 22525 72291 72292 |
Vertebroplasty/ Kyphoplasty |
Yes | Yes |
S2360 S2361 |
Vertebroplasty/ Kyphoplasty |
Yes | No (Investigational, Non-covered) |
Medical necessity criteria for Group and Individual members can be either Milliman® Care Guidelines or Asuris Medical Policy. Centers for Medicare & Medicaid Services (CMS) Policy, Milliman Care Guidelines or Asuris Medical Policy may be used for Asuris TruAdvantage members. The complete Medical Policy Manual is available at http://blue.regence.com/trgmedpol/index.html.
Note from the editor (8/5/10): Added "Investigational, Non-covered" to the table.