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12465 Results

Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)

Service Code
22845 (CPT) Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure)

Service Code
22846 (CPT) Anterior instrumentation; 4 to 7 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.

Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure)

Service Code
22847 (CPT) Anterior instrumentation; 8 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.

Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure)

Service Code
22848 (CPT) Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (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.

Reinsertion of spinal fixation device

Service Code
22849 (CPT) Reinsertion of spinal fixation device
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.

Removal of posterior nonsegmental instrumentation (eg, Harrington rod)

Service Code
22850 (CPT) Removal of posterior nonsegmental instrumentation (eg, Harrington rod)
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.

Removal of posterior segmental instrumentation

Service Code
22852 (CPT) Removal of posterior segmental instrumentation
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.

Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each inter

Service Code
22853 (CPT) Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each inter
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete)

Service Code
22854 (CPT) Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal of anterior instrumentation

Service Code
22855 (CPT) Removal of anterior instrumentation
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.

Spinal Surgeries

Service Code
22856 (CPT) Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical
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

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

  • 6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

Please submit your request to Evolent

Resources

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar

Service Code
22857 (CPT) Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition t

Service Code
22858 (CPT) Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition t
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary

Service Code
22859 (CPT) Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary
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.

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar (List separately in addition to code for primary procedure)

Service Code
22860 (CPT) Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar (List separately in addition to code for primary procedure)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Spinal Surgeries

Service Code
22861 (CPT) Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical
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

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

Limits

Single-level procedure only.

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

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

Exclusions

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

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

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

  • 6. Anatomical deformity such as ankylosing spondylitis or previous

fracture;

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

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

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

osteomalacia; or

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

more of the following conditions:

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

Place of Service

Inpatient, Outpatient.

How to Submit

Please submit your request to Evolent

Resources

Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar

Service Code
22862 (CPT) Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical

Service Code
22864 (CPT) Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar

Service Code
22865 (CPT) Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Unlisted procedure, spine

Service Code
22899 (CPT) Unlisted procedure, spine
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent