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12465 Results

Creation of lesion of spinal cord by stereotactic method, percutaneous, any modality (including stimulation and/or recording)

Service Code
63600 (CPT) Creation of lesion of spinal cord by stereotactic method, percutaneous, any modality (including stimulation and/or recording)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stereotactic stimulation of spinal cord, percutaneous, separate procedure not followed by other surgery

Service Code
63610 (CPT) Stereotactic stimulation of spinal cord, percutaneous, separate procedure not followed by other surgery
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion

Service Code
63620 (CPT) Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure)

Service Code
63621 (CPT) Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Spinal Cord Stimulation (SCS)

Service Code
63650 (CPT) Percutaneous implantation of neurostimulator electrode array, epidural
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Spinal cord stimulation (SCS), also known as a dorsal column stimulator, is an implantable medical device used to treat chronic intractable neuropathic pain. A small wire (called a lead) connected to a power source is surgically implanted under the skin. Low-level electrical signals are then transmitted through the lead to the spinal cord or to specific nerves to block pain signals from reaching the brain. Using a remote control, a patient can turn the current on and off, or adjust the intensity. The sensations, or paresthesias, derived from the stimulator are different for everyone. Most patients describe it as a pleasant tingling sensation, subsequently altering the perception of pain and providing analgesia. Implantation of the spinal cord stimulator is typically a two-step process. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed, defined as at least 50% reduction in pain, the electrodes and radio receiver/transducer are permanently implanted. This is a reversible therapy and results in no intended neuroablation, or nerve destruction.

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

Limits

Trial stimulation must use a temporarily implanted electrode for a minimum of 48 hours before permanent implantation. Billing units: one unit per date of service for the applicable procedure codes.

Exclusions

SCS is not covered and may be considered investigational for all other indications, including treatment of the following:

  • a. Critical limb ischemia as a technique to forestall amputation.
  • b. Visceral pain.
  • c. Drug-refractory chronic cluster headaches.
  • d. Nociceptive pain (resulting from irritation, not damage to the nerves).
  • e. Central deafferentation pain (related to central nervous system damage from a stroke or spinal cord injury).
  • f. Pregnant beneficiaries.
  • g. Chronic refractory angina pectoris.

Place of Service

Inpatient, Outpatient. 95970 through 95973 may also be billed in the office setting.

How to Submit

Please submit your request to Evolent

Resources

Spinal Cord Stimulation (SCS)

Service Code
63655 (CPT) Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Spinal cord stimulation (SCS), also known as a dorsal column stimulator, is an implantable medical device used to treat chronic intractable neuropathic pain. A small wire (called a lead) connected to a power source is surgically implanted under the skin. Low-level electrical signals are then transmitted through the lead to the spinal cord or to specific nerves to block pain signals from reaching the brain. Using a remote control, a patient can turn the current on and off, or adjust the intensity. The sensations, or paresthesias, derived from the stimulator are different for everyone. Most patients describe it as a pleasant tingling sensation, subsequently altering the perception of pain and providing analgesia. Implantation of the spinal cord stimulator is typically a two-step process. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed, defined as at least 50% reduction in pain, the electrodes and radio receiver/transducer are permanently implanted. This is a reversible therapy and results in no intended neuroablation, or nerve destruction.

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

Limits

Trial stimulation must use a temporarily implanted electrode for a minimum of 48 hours before permanent implantation. Billing units: one unit per date of service for the applicable procedure codes.

Exclusions

SCS is not covered and may be considered investigational for all other indications, including treatment of the following:

  • a. Critical limb ischemia as a technique to forestall amputation.
  • b. Visceral pain.
  • c. Drug-refractory chronic cluster headaches.
  • d. Nociceptive pain (resulting from irritation, not damage to the nerves).
  • e. Central deafferentation pain (related to central nervous system damage from a stroke or spinal cord injury).
  • f. Pregnant beneficiaries.
  • g. Chronic refractory angina pectoris.

Place of Service

Inpatient, Outpatient. 95970 through 95973 may also be billed in the office setting.

How to Submit

Please submit your request to Evolent

Resources

Spinal Cord Stimulation (SCS)

Service Code
63661 (CPT) Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Spinal cord stimulation (SCS), also known as a dorsal column stimulator, is an implantable medical device used to treat chronic intractable neuropathic pain. A small wire (called a lead) connected to a power source is surgically implanted under the skin. Low-level electrical signals are then transmitted through the lead to the spinal cord or to specific nerves to block pain signals from reaching the brain. Using a remote control, a patient can turn the current on and off, or adjust the intensity. The sensations, or paresthesias, derived from the stimulator are different for everyone. Most patients describe it as a pleasant tingling sensation, subsequently altering the perception of pain and providing analgesia. Implantation of the spinal cord stimulator is typically a two-step process. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed, defined as at least 50% reduction in pain, the electrodes and radio receiver/transducer are permanently implanted. This is a reversible therapy and results in no intended neuroablation, or nerve destruction.

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

Limits

Trial stimulation must use a temporarily implanted electrode for a minimum of 48 hours before permanent implantation. Billing units: one unit per date of service for the applicable procedure codes.

Exclusions

SCS is not covered and may be considered investigational for all other indications, including treatment of the following:

  • a. Critical limb ischemia as a technique to forestall amputation.
  • b. Visceral pain.
  • c. Drug-refractory chronic cluster headaches.
  • d. Nociceptive pain (resulting from irritation, not damage to the nerves).
  • e. Central deafferentation pain (related to central nervous system damage from a stroke or spinal cord injury).
  • f. Pregnant beneficiaries.
  • g. Chronic refractory angina pectoris.

Place of Service

Inpatient, Outpatient. 95970 through 95973 may also be billed in the office setting.

How to Submit

Please submit your request to Evolent

Resources

Spinal Cord Stimulation (SCS)

Service Code
63662 (CPT) Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Spinal cord stimulation (SCS), also known as a dorsal column stimulator, is an implantable medical device used to treat chronic intractable neuropathic pain. A small wire (called a lead) connected to a power source is surgically implanted under the skin. Low-level electrical signals are then transmitted through the lead to the spinal cord or to specific nerves to block pain signals from reaching the brain. Using a remote control, a patient can turn the current on and off, or adjust the intensity. The sensations, or paresthesias, derived from the stimulator are different for everyone. Most patients describe it as a pleasant tingling sensation, subsequently altering the perception of pain and providing analgesia. Implantation of the spinal cord stimulator is typically a two-step process. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed, defined as at least 50% reduction in pain, the electrodes and radio receiver/transducer are permanently implanted. This is a reversible therapy and results in no intended neuroablation, or nerve destruction.

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

Limits

Trial stimulation must use a temporarily implanted electrode for a minimum of 48 hours before permanent implantation. Billing units: one unit per date of service for the applicable procedure codes.

Exclusions

SCS is not covered and may be considered investigational for all other indications, including treatment of the following:

  • a. Critical limb ischemia as a technique to forestall amputation.
  • b. Visceral pain.
  • c. Drug-refractory chronic cluster headaches.
  • d. Nociceptive pain (resulting from irritation, not damage to the nerves).
  • e. Central deafferentation pain (related to central nervous system damage from a stroke or spinal cord injury).
  • f. Pregnant beneficiaries.
  • g. Chronic refractory angina pectoris.

Place of Service

Inpatient, Outpatient. 95970 through 95973 may also be billed in the office setting.

How to Submit

Please submit your request to Evolent

Resources

Spinal Cord Stimulation (SCS)

Service Code
63663 (CPT) Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Spinal cord stimulation (SCS), also known as a dorsal column stimulator, is an implantable medical device used to treat chronic intractable neuropathic pain. A small wire (called a lead) connected to a power source is surgically implanted under the skin. Low-level electrical signals are then transmitted through the lead to the spinal cord or to specific nerves to block pain signals from reaching the brain. Using a remote control, a patient can turn the current on and off, or adjust the intensity. The sensations, or paresthesias, derived from the stimulator are different for everyone. Most patients describe it as a pleasant tingling sensation, subsequently altering the perception of pain and providing analgesia. Implantation of the spinal cord stimulator is typically a two-step process. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed, defined as at least 50% reduction in pain, the electrodes and radio receiver/transducer are permanently implanted. This is a reversible therapy and results in no intended neuroablation, or nerve destruction.

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

Limits

Trial stimulation must use a temporarily implanted electrode for a minimum of 48 hours before permanent implantation. Billing units: one unit per date of service for the applicable procedure codes.

Exclusions

SCS is not covered and may be considered investigational for all other indications, including treatment of the following:

  • a. Critical limb ischemia as a technique to forestall amputation.
  • b. Visceral pain.
  • c. Drug-refractory chronic cluster headaches.
  • d. Nociceptive pain (resulting from irritation, not damage to the nerves).
  • e. Central deafferentation pain (related to central nervous system damage from a stroke or spinal cord injury).
  • f. Pregnant beneficiaries.
  • g. Chronic refractory angina pectoris.

Place of Service

Inpatient, Outpatient. 95970 through 95973 may also be billed in the office setting.

How to Submit

Please submit your request to Evolent

Resources

Spinal Cord Stimulation (SCS)

Service Code
63664 (CPT) Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Spinal cord stimulation (SCS), also known as a dorsal column stimulator, is an implantable medical device used to treat chronic intractable neuropathic pain. A small wire (called a lead) connected to a power source is surgically implanted under the skin. Low-level electrical signals are then transmitted through the lead to the spinal cord or to specific nerves to block pain signals from reaching the brain. Using a remote control, a patient can turn the current on and off, or adjust the intensity. The sensations, or paresthesias, derived from the stimulator are different for everyone. Most patients describe it as a pleasant tingling sensation, subsequently altering the perception of pain and providing analgesia. Implantation of the spinal cord stimulator is typically a two-step process. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed, defined as at least 50% reduction in pain, the electrodes and radio receiver/transducer are permanently implanted. This is a reversible therapy and results in no intended neuroablation, or nerve destruction.

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

Limits

Trial stimulation must use a temporarily implanted electrode for a minimum of 48 hours before permanent implantation. Billing units: one unit per date of service for the applicable procedure codes.

Exclusions

SCS is not covered and may be considered investigational for all other indications, including treatment of the following:

  • a. Critical limb ischemia as a technique to forestall amputation.
  • b. Visceral pain.
  • c. Drug-refractory chronic cluster headaches.
  • d. Nociceptive pain (resulting from irritation, not damage to the nerves).
  • e. Central deafferentation pain (related to central nervous system damage from a stroke or spinal cord injury).
  • f. Pregnant beneficiaries.
  • g. Chronic refractory angina pectoris.

Place of Service

Inpatient, Outpatient. 95970 through 95973 may also be billed in the office setting.

How to Submit

Please submit your request to Evolent

Resources

Spinal Cord Stimulation (SCS)

Service Code
63685 (CPT) Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Spinal cord stimulation (SCS), also known as a dorsal column stimulator, is an implantable medical device used to treat chronic intractable neuropathic pain. A small wire (called a lead) connected to a power source is surgically implanted under the skin. Low-level electrical signals are then transmitted through the lead to the spinal cord or to specific nerves to block pain signals from reaching the brain. Using a remote control, a patient can turn the current on and off, or adjust the intensity. The sensations, or paresthesias, derived from the stimulator are different for everyone. Most patients describe it as a pleasant tingling sensation, subsequently altering the perception of pain and providing analgesia. Implantation of the spinal cord stimulator is typically a two-step process. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed, defined as at least 50% reduction in pain, the electrodes and radio receiver/transducer are permanently implanted. This is a reversible therapy and results in no intended neuroablation, or nerve destruction.

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

Limits

Trial stimulation must use a temporarily implanted electrode for a minimum of 48 hours before permanent implantation. Billing units: one unit per date of service for the applicable procedure codes.

Exclusions

SCS is not covered and may be considered investigational for all other indications, including treatment of the following:

  • a. Critical limb ischemia as a technique to forestall amputation.
  • b. Visceral pain.
  • c. Drug-refractory chronic cluster headaches.
  • d. Nociceptive pain (resulting from irritation, not damage to the nerves).
  • e. Central deafferentation pain (related to central nervous system damage from a stroke or spinal cord injury).
  • f. Pregnant beneficiaries.
  • g. Chronic refractory angina pectoris.

Place of Service

Inpatient, Outpatient. 95970 through 95973 may also be billed in the office setting.

How to Submit

Please submit your request to Evolent

Resources

Spinal Cord Stimulation (SCS)

Service Code
63688 (CPT) Revision or removal of implanted spinal neurostimulator pulse generator or receiver
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Spinal cord stimulation (SCS), also known as a dorsal column stimulator, is an implantable medical device used to treat chronic intractable neuropathic pain. A small wire (called a lead) connected to a power source is surgically implanted under the skin. Low-level electrical signals are then transmitted through the lead to the spinal cord or to specific nerves to block pain signals from reaching the brain. Using a remote control, a patient can turn the current on and off, or adjust the intensity. The sensations, or paresthesias, derived from the stimulator are different for everyone. Most patients describe it as a pleasant tingling sensation, subsequently altering the perception of pain and providing analgesia. Implantation of the spinal cord stimulator is typically a two-step process. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed, defined as at least 50% reduction in pain, the electrodes and radio receiver/transducer are permanently implanted. This is a reversible therapy and results in no intended neuroablation, or nerve destruction.

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

Limits

Trial stimulation must use a temporarily implanted electrode for a minimum of 48 hours before permanent implantation. Billing units: one unit per date of service for the applicable procedure codes.

Exclusions

SCS is not covered and may be considered investigational for all other indications, including treatment of the following:

  • a. Critical limb ischemia as a technique to forestall amputation.
  • b. Visceral pain.
  • c. Drug-refractory chronic cluster headaches.
  • d. Nociceptive pain (resulting from irritation, not damage to the nerves).
  • e. Central deafferentation pain (related to central nervous system damage from a stroke or spinal cord injury).
  • f. Pregnant beneficiaries.
  • g. Chronic refractory angina pectoris.

Place of Service

Inpatient, Outpatient. 95970 through 95973 may also be billed in the office setting.

How to Submit

Please submit your request to Evolent

Resources

Repair of meningocele; less than 5 cm diameter

Service Code
63700 (CPT) Repair of meningocele; less than 5 cm diameter
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.

Repair of meningocele; larger than 5 cm diameter

Service Code
63702 (CPT) Repair of meningocele; larger than 5 cm diameter
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.

Repair of myelomeningocele; less than 5 cm diameter

Service Code
63704 (CPT) Repair of myelomeningocele; less than 5 cm diameter
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.

Repair of myelomeningocele; larger than 5 cm diameter

Service Code
63706 (CPT) Repair of myelomeningocele; larger than 5 cm diameter
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.

Repair of dural/cerebrospinal fluid leak, not requiring laminectomy

Service Code
63707 (CPT) Repair of dural/cerebrospinal fluid leak, not requiring laminectomy
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.

Repair of dural/cerebrospinal fluid leak or pseudomeningocele, with laminectomy

Service Code
63709 (CPT) Repair of dural/cerebrospinal fluid leak or pseudomeningocele, with laminectomy
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.

Dural graft, spinal

Service Code
63710 (CPT) Dural graft, spinal
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.

Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other; including laminectomy

Service Code
63740 (CPT) Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other; including laminectomy
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.