PA Lookup
If you have questions about prior authorizations, please call:
Member and Recipient Service Line: 1-877-685-2415
Provider Support Service Line: 1-855-250-1539
Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic
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.
Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral
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.
Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code f
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.
Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance
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.
Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance
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.
Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance
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.
Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level
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.
Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure)
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.
Spinal Surgeries
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
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
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:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met
the specific criteria in Subsection 3.2 of this policy. Prior approval for home health services is required for the following:
- a. Miscellaneous Therapeutic Items and Supplies: Supply Procedure Code.
Refer to Attachment A: Code(s) for prior approval and limit specifications.
Submit prior approval requests via the secure NC Tracks Provider portal. PA requests cannot be submitted by paper via fax, email, postal service, or by phone.b. Medical supplies, appliances, and equipment not listed on the fee schedule may be considered for coverage, if submitted for prior authorization (PA) review of medical necessity. For a beneficiary aged 21 or older, please follow the procedure detailed in Attachment B and posted on the Home Health Services webpage at https://medicaid.ncdhhs.gov/.
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
Please submit your request to Evolent
Resources
Spinal Surgeries
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
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
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
See Evolent site for specific requirements
Reauthorization Guidelines
See Evolent site for specific requirements
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
Please submit your request to Evolent
Resources
Spinal Surgeries
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
See Evolent site for specific requirements
Reauthorization Guidelines
See Evolent site for specific requirements
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
Please submit your request to Evolent
Resources
Spinal Surgeries
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
See Evolent site for specific requirements
Reauthorization Guidelines
See Evolent site for specific requirements
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
Please submit your request to Evolent
Resources
Spinal Surgeries
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
See Evolent site for specific requirements
Reauthorization Guidelines
See Evolent site for specific requirements
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
Please submit your request to Evolent
Resources
Spinal Surgeries
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
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
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
See Evolent site for specific requirements
Reauthorization Guidelines
See Evolent site for specific requirements
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
Please submit your request to Evolent
Resources
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.