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12465 Results

Spinal Surgeries

Service Code
63172 (CPT) Laminectomy with drainage of intramedullary cyst/syrinx; to subarachnoid space
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.

Authorization Guidelines

The provider(s) shall submit the following:

  • a. the prior approval request; and
  • b. all health records and any other records that support the beneficiary has met

the specific criteria in this policy.

  • c. if the Medicaid beneficiary is under 21 years of age, information supporting

that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

The provider shall submit the following information along with the request for surgery:

  • a. A signed letter of medical necessity clearly documenting diagnosis and

date of symptom onset, the specific procedure(s) requested with CPT code(s) and disc level(s) indicated;

  • b. Office notes, including a current history and physical exam within the past

thirty days;

  • c. Detailed documentation of extent and response to conservative medical

management, including length of treatment, outcomes of any procedural interventions, medication use (including dose and frequency), participation in physical therapy or a home exercise program, and beneficiary acceptance of recommended lifestyle modifications;

  • d. All radiology reports relevant to the surgical request. Imaging must be

read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede;

  • e. Post-operative plan of care; and
  • f. Medical clearance reports (as appropriate).

Limits

Single-level procedure only.

Covered only for cervical artificial disc implantation from C3-4 to C6-7.

Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.

Exclusions

Medicaid shall not cover artificial disc implantation for the following conditions:

  • 1. Planned simultaneous, multilevel disc implantation;
  • 2. Combined use of artificial disc and fusion (hybrid procedure);
  • 3. Prior surgery at the level to be treated;
  • 4. Previous fusion at the same or adjacent level;
  • 5. Instability as defined by translation greater than 3 millimeters’ difference

between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;

  • 6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

  • 7. Ossification of the posterior longitudinal ligament (OPLL)
  • 8. Severe spondylosis defined as greater than fifty (50) percent disc height

loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;

  • 9. Rheumatoid arthritis or other autoimmune disease;
  • 10. Presence of facet arthritis;
  • 11. Sensitivity or allergy to implant materials
  • 12. Active systemic or site infection;
  • 13. Metabolic bone disease such as osteoporosis, osteopenia, or

osteomalacia; or

  • 14. Malignancy of the cervical spine.
  • b. Medicaid shall not cover spinal surgery if the sole indication is any one or

more of the following conditions:

  • 1. Disc herniation;
  • 2. Annular tears;
  • 3. Degenerative disc disease;
  • 4. Initial discectomy or laminectomy for neural structure decompression;
  • 5. Facet syndrome; or
  • 6. Back pain without any clear cause on imaging

Place of Service

Inpatient, Outpatient.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Resources

Spinal Surgeries

Service Code
63173 (CPT) Laminectomy with drainage of intramedullary cyst/syrinx; to peritoneal or pleural space
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.

Authorization Guidelines

The provider(s) shall submit the following:

  • a. the prior approval request; and
  • b. all health records and any other records that support the beneficiary has met

the specific criteria in this policy.

  • c. if the Medicaid beneficiary is under 21 years of age, information supporting

that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

The provider shall submit the following information along with the request for surgery:

  • a. A signed letter of medical necessity clearly documenting diagnosis and

date of symptom onset, the specific procedure(s) requested with CPT code(s) and disc level(s) indicated;

  • b. Office notes, including a current history and physical exam within the past

thirty days;

  • c. Detailed documentation of extent and response to conservative medical

management, including length of treatment, outcomes of any procedural interventions, medication use (including dose and frequency), participation in physical therapy or a home exercise program, and beneficiary acceptance of recommended lifestyle modifications;

  • d. All radiology reports relevant to the surgical request. Imaging must be

read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede;

  • e. Post-operative plan of care; and
  • f. Medical clearance reports (as appropriate).

Limits

Single-level procedure only.

Covered only for cervical artificial disc implantation from C3-4 to C6-7.

Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.

Exclusions

Medicaid shall not cover artificial disc implantation for the following conditions:

  • 1. Planned simultaneous, multilevel disc implantation;
  • 2. Combined use of artificial disc and fusion (hybrid procedure);
  • 3. Prior surgery at the level to be treated;
  • 4. Previous fusion at the same or adjacent level;
  • 5. Instability as defined by translation greater than 3 millimeters’ difference

between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;

  • 6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

  • 7. Ossification of the posterior longitudinal ligament (OPLL)
  • 8. Severe spondylosis defined as greater than fifty (50) percent disc height

loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;

  • 9. Rheumatoid arthritis or other autoimmune disease;
  • 10. Presence of facet arthritis;
  • 11. Sensitivity or allergy to implant materials
  • 12. Active systemic or site infection;
  • 13. Metabolic bone disease such as osteoporosis, osteopenia, or

osteomalacia; or

  • 14. Malignancy of the cervical spine.
  • b. Medicaid shall not cover spinal surgery if the sole indication is any one or

more of the following conditions:

  • 1. Disc herniation;
  • 2. Annular tears;
  • 3. Degenerative disc disease;
  • 4. Initial discectomy or laminectomy for neural structure decompression;
  • 5. Facet syndrome; or
  • 6. Back pain without any clear cause on imaging

Place of Service

Inpatient, Outpatient.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Resources

Spinal Surgeries

Service Code
63185 (CPT) Laminectomy with rhizotomy; 1 or 2 segments
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.

Authorization Guidelines

The provider(s) shall submit the following:

  • a. the prior approval request; and
  • b. all health records and any other records that support the beneficiary has met

the specific criteria in this policy.

  • c. if the Medicaid beneficiary is under 21 years of age, information supporting

that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

The provider shall submit the following information along with the request for surgery:

  • a. A signed letter of medical necessity clearly documenting diagnosis and

date of symptom onset, the specific procedure(s) requested with CPT code(s) and disc level(s) indicated;

  • b. Office notes, including a current history and physical exam within the past

thirty days;

  • c. Detailed documentation of extent and response to conservative medical

management, including length of treatment, outcomes of any procedural interventions, medication use (including dose and frequency), participation in physical therapy or a home exercise program, and beneficiary acceptance of recommended lifestyle modifications;

  • d. All radiology reports relevant to the surgical request. Imaging must be

read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede;

  • e. Post-operative plan of care; and
  • f. Medical clearance reports (as appropriate).

Limits

Single-level procedure only.

Covered only for cervical artificial disc implantation from C3-4 to C6-7.

Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.

Exclusions

Medicaid shall not cover artificial disc implantation for the following conditions:

  • 1. Planned simultaneous, multilevel disc implantation;
  • 2. Combined use of artificial disc and fusion (hybrid procedure);
  • 3. Prior surgery at the level to be treated;
  • 4. Previous fusion at the same or adjacent level;
  • 5. Instability as defined by translation greater than 3 millimeters’ difference

between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;

  • 6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

  • 7. Ossification of the posterior longitudinal ligament (OPLL)
  • 8. Severe spondylosis defined as greater than fifty (50) percent disc height

loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;

  • 9. Rheumatoid arthritis or other autoimmune disease;
  • 10. Presence of facet arthritis;
  • 11. Sensitivity or allergy to implant materials
  • 12. Active systemic or site infection;
  • 13. Metabolic bone disease such as osteoporosis, osteopenia, or

osteomalacia; or

  • 14. Malignancy of the cervical spine.
  • b. Medicaid shall not cover spinal surgery if the sole indication is any one or

more of the following conditions:

  • 1. Disc herniation;
  • 2. Annular tears;
  • 3. Degenerative disc disease;
  • 4. Initial discectomy or laminectomy for neural structure decompression;
  • 5. Facet syndrome; or
  • 6. Back pain without any clear cause on imaging

Place of Service

Inpatient, Outpatient.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Resources

Spinal Surgeries

Service Code
63190 (CPT) Laminectomy with rhizotomy; more than 2 segments
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.

Authorization Guidelines

The provider(s) shall submit the following:

  • a. the prior approval request; and
  • b. all health records and any other records that support the beneficiary has met

the specific criteria in this policy.

  • c. if the Medicaid beneficiary is under 21 years of age, information supporting

that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

The provider shall submit the following information along with the request for surgery:

  • a. A signed letter of medical necessity clearly documenting diagnosis and

date of symptom onset, the specific procedure(s) requested with CPT code(s) and disc level(s) indicated;

  • b. Office notes, including a current history and physical exam within the past

thirty days;

  • c. Detailed documentation of extent and response to conservative medical

management, including length of treatment, outcomes of any procedural interventions, medication use (including dose and frequency), participation in physical therapy or a home exercise program, and beneficiary acceptance of recommended lifestyle modifications;

  • d. All radiology reports relevant to the surgical request. Imaging must be

read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede;

  • e. Post-operative plan of care; and
  • f. Medical clearance reports (as appropriate).

Limits

Single-level procedure only.

Covered only for cervical artificial disc implantation from C3-4 to C6-7.

Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.

Exclusions

Medicaid shall not cover artificial disc implantation for the following conditions:

  • 1. Planned simultaneous, multilevel disc implantation;
  • 2. Combined use of artificial disc and fusion (hybrid procedure);
  • 3. Prior surgery at the level to be treated;
  • 4. Previous fusion at the same or adjacent level;
  • 5. Instability as defined by translation greater than 3 millimeters’ difference

between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;

  • 6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

  • 7. Ossification of the posterior longitudinal ligament (OPLL)
  • 8. Severe spondylosis defined as greater than fifty (50) percent disc height

loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;

  • 9. Rheumatoid arthritis or other autoimmune disease;
  • 10. Presence of facet arthritis;
  • 11. Sensitivity or allergy to implant materials
  • 12. Active systemic or site infection;
  • 13. Metabolic bone disease such as osteoporosis, osteopenia, or

osteomalacia; or

  • 14. Malignancy of the cervical spine.
  • b. Medicaid shall not cover spinal surgery if the sole indication is any one or

more of the following conditions:

  • 1. Disc herniation;
  • 2. Annular tears;
  • 3. Degenerative disc disease;
  • 4. Initial discectomy or laminectomy for neural structure decompression;
  • 5. Facet syndrome; or
  • 6. Back pain without any clear cause on imaging

Place of Service

Inpatient, Outpatient.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Resources

Spinal Surgeries

Service Code
63191 (CPT) Laminectomy with section of spinal accessory nerve
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.

Authorization Guidelines

The provider(s) shall submit the following:

  • a. the prior approval request; and
  • b. all health records and any other records that support the beneficiary has met

the specific criteria in this policy.

  • c. if the Medicaid beneficiary is under 21 years of age, information supporting

that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

The provider shall submit the following information along with the request for surgery:

  • a. A signed letter of medical necessity clearly documenting diagnosis and

date of symptom onset, the specific procedure(s) requested with CPT code(s) and disc level(s) indicated;

  • b. Office notes, including a current history and physical exam within the past

thirty days;

  • c. Detailed documentation of extent and response to conservative medical

management, including length of treatment, outcomes of any procedural interventions, medication use (including dose and frequency), participation in physical therapy or a home exercise program, and beneficiary acceptance of recommended lifestyle modifications;

  • d. All radiology reports relevant to the surgical request. Imaging must be

read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede;

  • e. Post-operative plan of care; and
  • f. Medical clearance reports (as appropriate).

Limits

Single-level procedure only.

Covered only for cervical artificial disc implantation from C3-4 to C6-7.

Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.

Exclusions

Medicaid shall not cover artificial disc implantation for the following conditions:

  • 1. Planned simultaneous, multilevel disc implantation;
  • 2. Combined use of artificial disc and fusion (hybrid procedure);
  • 3. Prior surgery at the level to be treated;
  • 4. Previous fusion at the same or adjacent level;
  • 5. Instability as defined by translation greater than 3 millimeters’ difference

between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;

  • 6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

  • 7. Ossification of the posterior longitudinal ligament (OPLL)
  • 8. Severe spondylosis defined as greater than fifty (50) percent disc height

loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;

  • 9. Rheumatoid arthritis or other autoimmune disease;
  • 10. Presence of facet arthritis;
  • 11. Sensitivity or allergy to implant materials
  • 12. Active systemic or site infection;
  • 13. Metabolic bone disease such as osteoporosis, osteopenia, or

osteomalacia; or

  • 14. Malignancy of the cervical spine.
  • b. Medicaid shall not cover spinal surgery if the sole indication is any one or

more of the following conditions:

  • 1. Disc herniation;
  • 2. Annular tears;
  • 3. Degenerative disc disease;
  • 4. Initial discectomy or laminectomy for neural structure decompression;
  • 5. Facet syndrome; or
  • 6. Back pain without any clear cause on imaging

Place of Service

Inpatient, Outpatient.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Resources

Spinal Surgeries

Service Code
63197 (CPT) Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage; thoracic
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.

Authorization Guidelines

The provider(s) shall submit the following:

  • a. the prior approval request; and
  • b. all health records and any other records that support the beneficiary has met

the specific criteria in this policy.

  • c. if the Medicaid beneficiary is under 21 years of age, information supporting

that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

The provider shall submit the following information along with the request for surgery:

  • a. A signed letter of medical necessity clearly documenting diagnosis and

date of symptom onset, the specific procedure(s) requested with CPT code(s) and disc level(s) indicated;

  • b. Office notes, including a current history and physical exam within the past

thirty days;

  • c. Detailed documentation of extent and response to conservative medical

management, including length of treatment, outcomes of any procedural interventions, medication use (including dose and frequency), participation in physical therapy or a home exercise program, and beneficiary acceptance of recommended lifestyle modifications;

  • d. All radiology reports relevant to the surgical request. Imaging must be

read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede;

  • e. Post-operative plan of care; and
  • f. Medical clearance reports (as appropriate).

Limits

Single-level procedure only.

Covered only for cervical artificial disc implantation from C3-4 to C6-7.

Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.

Exclusions

Medicaid shall not cover artificial disc implantation for the following conditions:

  • 1. Planned simultaneous, multilevel disc implantation;
  • 2. Combined use of artificial disc and fusion (hybrid procedure);
  • 3. Prior surgery at the level to be treated;
  • 4. Previous fusion at the same or adjacent level;
  • 5. Instability as defined by translation greater than 3 millimeters’ difference

between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;

  • 6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

  • 7. Ossification of the posterior longitudinal ligament (OPLL)
  • 8. Severe spondylosis defined as greater than fifty (50) percent disc height

loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;

  • 9. Rheumatoid arthritis or other autoimmune disease;
  • 10. Presence of facet arthritis;
  • 11. Sensitivity or allergy to implant materials
  • 12. Active systemic or site infection;
  • 13. Metabolic bone disease such as osteoporosis, osteopenia, or

osteomalacia; or

  • 14. Malignancy of the cervical spine.
  • b. Medicaid shall not cover spinal surgery if the sole indication is any one or

more of the following conditions:

  • 1. Disc herniation;
  • 2. Annular tears;
  • 3. Degenerative disc disease;
  • 4. Initial discectomy or laminectomy for neural structure decompression;
  • 5. Facet syndrome; or
  • 6. Back pain without any clear cause on imaging

Place of Service

Inpatient, Outpatient.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Resources

Spinal Surgeries

Service Code
63200 (CPT) Laminectomy, with release of tethered spinal cord, lumbar
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

There are many causes of back pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital or developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause back pain; such as infection, hemorrhage, fracture and tumor with or without associated symptoms. Although there are numerous causes of back pain, it is imperative to distinguish whether the pain is actually generated by a primary spine-related condition, or whether it is caused by some other body system (such as a kidney disorder or aortic aneurysm) mimicking back pain. Mild to moderate back pain arising from numerous etiologies are often treated effectively with conservative medical management. Non-surgical measures commonly used to treat back pain are medication, activity and behavioral modification, heat or ice application, orthotics (back brace or corset), or spinal injections. Surgical intervention is only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (such as fractures, neurologic compromise, or cancer) and require immediate surgical management. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression on the spinal cord or nerve roots. Depending on the location and cause of the compression, this may be accomplished by performing a discectomy, laminectomy, laminotomy, foraminotomy, foraminectomy, corpectomy, facetectomy, or spinal fusion. Spinal fusion is a surgical procedure that joins two or more back vertebrae together to heal into one solid bony structure. This procedure is also known as arthrodesis. This surgery may be used to treat spinal instability, cord compression due to severe herniated discs, protruded or extruded discs, or arthritis, fractures in the spine, or destruction of the vertebrae by infection or tumor.

Authorization Guidelines

The provider(s) shall submit the following:

  • a. the prior approval request; and
  • b. all health records and any other records that support the beneficiary has met

the specific criteria in this policy.

  • c. if the Medicaid beneficiary is under 21 years of age, information supporting

that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

The provider shall submit the following information along with the request for surgery:

  • a. A signed letter of medical necessity clearly documenting diagnosis and

date of symptom onset, the specific procedure(s) requested with CPT code(s) and disc level(s) indicated;

  • b. Office notes, including a current history and physical exam within the past

thirty days;

  • c. Detailed documentation of extent and response to conservative medical

management, including length of treatment, outcomes of any procedural interventions, medication use (including dose and frequency), participation in physical therapy or a home exercise program, and beneficiary acceptance of recommended lifestyle modifications;

  • d. All radiology reports relevant to the surgical request. Imaging must be

read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede;

  • e. Post-operative plan of care; and
  • f. Medical clearance reports (as appropriate).

Limits

Single-level procedure only.

Covered only for cervical artificial disc implantation from C3-4 to C6-7.

Beneficiary must have reached skeletal maturity. Cervical decompression is not covered unless all other reasonable sources of pain have been ruled out.

Exclusions

Medicaid shall not cover artificial disc implantation for the following conditions:

  • 1. Planned simultaneous, multilevel disc implantation;
  • 2. Combined use of artificial disc and fusion (hybrid procedure);
  • 3. Prior surgery at the level to be treated;
  • 4. Previous fusion at the same or adjacent level;
  • 5. Instability as defined by translation greater than 3 millimeters’ difference

between lateral flexion-extension views at the symptomatic level or eleven (11) degrees of angular difference between lateral flexionextension views at the symptomatic level;

  • 6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

  • 7. Ossification of the posterior longitudinal ligament (OPLL)
  • 8. Severe spondylosis defined as greater than fifty (50) percent disc height

loss compared to minimally or non-degenerated levels, bridging osteophytes, or absence of motion on flexion-extension views at the symptomatic site;

  • 9. Rheumatoid arthritis or other autoimmune disease;
  • 10. Presence of facet arthritis;
  • 11. Sensitivity or allergy to implant materials
  • 12. Active systemic or site infection;
  • 13. Metabolic bone disease such as osteoporosis, osteopenia, or

osteomalacia; or

  • 14. Malignancy of the cervical spine.
  • b. Medicaid shall not cover spinal surgery if the sole indication is any one or

more of the following conditions:

  • 1. Disc herniation;
  • 2. Annular tears;
  • 3. Degenerative disc disease;
  • 4. Initial discectomy or laminectomy for neural structure decompression;
  • 5. Facet syndrome; or
  • 6. Back pain without any clear cause on imaging

Place of Service

Inpatient, Outpatient.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Resources

Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; cervical

Service Code
63250 (CPT) Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; cervical
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracic

Service Code
63251 (CPT) Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracic
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar

Service Code
63252 (CPT) Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical

Service Code
63265 (CPT) Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic

Service Code
63266 (CPT) Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar

Service Code
63267 (CPT) Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral

Service Code
63268 (CPT) Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical

Service Code
63270 (CPT) Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; thoracic

Service Code
63271 (CPT) Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; thoracic
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar

Service Code
63272 (CPT) Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; sacral

Service Code
63273 (CPT) Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; sacral
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical

Service Code
63275 (CPT) Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, thoracic

Service Code
63276 (CPT) Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, thoracic
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.