PA Lookup

Spinal Surgeries

Service Code

22634 (CPT) Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspa

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Authorization Guidelines

The provider(s) shall submit the following:

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

the specific criteria in this policy.

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

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

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

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

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

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

thirty days;

c. Detailed documentation of extent and response to conservative medical

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

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

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

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

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

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

Resources

Spinal Surgeries

Service Code

22634 (CPT) Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspa

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Authorization Guidelines

The provider(s) shall submit the following:

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

the specific criteria in this policy.

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

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

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

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

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

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

thirty days;

c. Detailed documentation of extent and response to conservative medical

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

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

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

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

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

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

Resources

Spinal Surgeries

Service Code

22634 (CPT) Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspa

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Authorization Guidelines

The provider(s) shall submit the following:

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

the specific criteria in this policy.

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

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

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

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

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

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

thirty days;

c. Detailed documentation of extent and response to conservative medical

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

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

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

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

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

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

Resources

Spinal Surgeries

Service Code

22634 (CPT) Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspa

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Authorization Guidelines

The provider(s) shall submit the following:

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

the specific criteria in this policy.

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

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

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

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

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

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

thirty days;

c. Detailed documentation of extent and response to conservative medical

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

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

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

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

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

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

Resources

Spinal Surgeries

Service Code

22634 (CPT) Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspa

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Authorization Guidelines

The provider(s) shall submit the following:

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

the specific criteria in this policy.

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

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

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

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

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

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

thirty days;

c. Detailed documentation of extent and response to conservative medical

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

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

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

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

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

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

Resources

Spinal Surgeries

Service Code

22634 (CPT) Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspa

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Authorization Guidelines

The provider(s) shall submit the following:

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

the specific criteria in this policy.

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

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

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

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

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

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

thirty days;

c. Detailed documentation of extent and response to conservative medical

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

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

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

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

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

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

Resources

Spinal Surgeries

Service Code

22800 (CPT) Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Authorization Guidelines

The provider(s) shall submit the following:

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

the specific criteria in this policy.

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

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

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

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

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

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

thirty days;

c. Detailed documentation of extent and response to conservative medical

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

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

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

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

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

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

Resources

Spinal Surgeries

Service Code

22802 (CPT) Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Authorization Guidelines

The provider(s) shall submit the following:

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

the specific criteria in this policy.

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

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

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

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

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

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

thirty days;

c. Detailed documentation of extent and response to conservative medical

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

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

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

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

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

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

Resources

Spinal Surgeries

Service Code

22804 (CPT) Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Authorization Guidelines

The provider(s) shall submit the following:

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

the specific criteria in this policy.

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

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

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

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

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

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

thirty days;

c. Detailed documentation of extent and response to conservative medical

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

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

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

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

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

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

Resources

Spinal Surgeries

Service Code

22808 (CPT) Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Authorization Guidelines

The provider(s) shall submit the following:

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

the specific criteria in this policy.

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

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

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

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

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

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

thirty days;

c. Detailed documentation of extent and response to conservative medical

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

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

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

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

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

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

Resources

Spinal Surgeries

Service Code

22810 (CPT) Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Authorization Guidelines

The provider(s) shall submit the following:

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

the specific criteria in this policy.

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

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

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

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

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

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

thirty days;

c. Detailed documentation of extent and response to conservative medical

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

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

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

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

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

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

Resources

Spinal Surgeries

Service Code

22812 (CPT) Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Authorization Guidelines

The provider(s) shall submit the following:

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

the specific criteria in this policy.

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

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

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

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

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

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

thirty days;

c. Detailed documentation of extent and response to conservative medical

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

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

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

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

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

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

Resources

Spinal Surgeries

Service Code

22818 (CPT) Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Authorization Guidelines

The provider(s) shall submit the following:

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

the specific criteria in this policy.

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

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

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

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

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

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

thirty days;

c. Detailed documentation of extent and response to conservative medical

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

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

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

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

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

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

Resources

Spinal Surgeries

Service Code

22819 (CPT) Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segments

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Authorization Guidelines

The provider(s) shall submit the following:

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

the specific criteria in this policy.

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

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

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

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

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

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

thirty days;

c. Detailed documentation of extent and response to conservative medical

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

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

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

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

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

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

Resources

Spinal Surgeries

Service Code

22830 (CPT) Exploration of spinal fusion

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Authorization Guidelines

The provider(s) shall submit the following:

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

the specific criteria in this policy.

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

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

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

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

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

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

thirty days;

c. Detailed documentation of extent and response to conservative medical

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

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

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

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

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

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

Resources

Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary proced

Service Code

22840 (CPT) Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary proced

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.

Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure)

Service Code

22841 (CPT) Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure)

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.

Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)

Service Code

22842 (CPT) Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)

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.

Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure)

Service Code

22843 (CPT) Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure)

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.

Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure)

Service Code

22844 (CPT) Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure)

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.

If you have questions about prior authorizations, please call:

Spinal Surgeries

Authorization Guidelines

Limits

Exclusions

Place of Service

How to Submit

Resources

Spinal Surgeries

Authorization Guidelines

Limits

Exclusions

Place of Service

How to Submit

Resources

Spinal Surgeries

Authorization Guidelines

Limits

Exclusions

Place of Service

How to Submit

Resources

Spinal Surgeries

Authorization Guidelines

Limits

Exclusions

Place of Service

How to Submit

Resources

Spinal Surgeries

Authorization Guidelines

Limits

Exclusions

Place of Service

How to Submit

Resources

Spinal Surgeries

Authorization Guidelines

Limits

Exclusions

Place of Service

How to Submit

Resources

Spinal Surgeries

Authorization Guidelines

Limits

Exclusions

Place of Service

How to Submit

Resources

Spinal Surgeries

Authorization Guidelines

Limits

Exclusions

Place of Service

How to Submit

Resources

Spinal Surgeries

Authorization Guidelines

Limits

Exclusions

Place of Service

How to Submit

Resources

Spinal Surgeries

Authorization Guidelines

Limits

Exclusions

Place of Service

How to Submit

Resources

Spinal Surgeries

Authorization Guidelines

Limits

Exclusions

Place of Service

How to Submit

Resources

Spinal Surgeries