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  • EmblemHealth Spine Surgery and Pain Management Therapies Program > Procedure Codes

    The following spine surgery and pain management procedure therapy codes require prior approval for both inpatient and outpatient procedures and therapies as part of this Program.

    Spine Surgery and Pain Management Procedure Therapy Codes
    Type of Procedure
    CPT/HCPCS Codes
    ICD-9 Procedure/ Diagnosis Codes
    ICD-10 Procedure/Diagnosis Codes
    Spinal Fusion
    0195T, 0196T, 0309T, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22851, 22852
    81.0, 81.00, 81.02, 81.03, 81.04, 81.05, 81.06, 81.07, 81.08, 81.62
    0RG0070, 0RG0071, 0RG007J, 0RG00J0, 0RG00J1, 0RG00JJ, 0RG00K0, 0RG00K1, 0RG00KJ, 0RG00Z0, 0RG00Z1, 0RG00ZJ, 0RG0370, 0RG0371, 0RG037J, 0RG03J0, 0RG03J1, 0RG03JJ, 0RG03K0, 0RG03K1, 0RG03KJ, 0RG03Z0, 0RG03Z1, 0RG03ZJ, 0RG0470, 0RG0471, 0RG047J, 0RG04J0, 0RG04J1, 0RG04JJ, 0RG04K0, 0RG04K1, 0RG04KJ, 0RG04Z0, 0RG04Z1, 0RG04ZJ, 0RG1070, 0RG1071, 0RG107J, 0RG10J0, 0RG10J1, 0RG10JJ, 0RG10K0, 0RG10K1, 0RG10KJ, 0RG10Z0, 0RG10Z1, 0RG10ZJ, 0RG1370, 0RG1371, 0RG137J, 0RG13J0, 0RG13J1, 0RG13JJ, 0RG13K0, 0RG13K1, 0RG13KJ, 0RG13Z0, 0RG13Z1, 0RG13ZJ, 0RG1470, 0RG1471, 0RG147J, 0RG14J0, 0RG14J1, 0RG14JJ, 0RG14K0, 0RG14K1, 0RG14KJ, 0RG14Z0, 0RG14Z1, 0RG14ZJ, 0RG4070, 0RG4071, 0RG407J, 0RG40J0, 0RG40J1, 0RG40JJ, 0RG40K0, 0RG40K1, 0RG40KJ, 0RG40Z0, 0RG40Z1, 0RG40ZJ, 0RG4370, 0RG4371, 0RG437J, 0RG43J0, 0RG43J1, 0RG43JJ, 0RG43K0, 0RG43K1, 0RG43KJ, 0RG43Z0, 0RG43Z1, 0RG43ZJ, 0RG4470, 0RG4471, 0RG447J, 0RG44J0, 0RG44J1, 0RG44JJ, 0RG44K0, 0RG44K1, 0RG44KJ, 0RG44Z0, 0RG44Z1, 0RG44ZJ, 0RG6070, 0RG6071, 0RG607J, 0RG60J0, 0RG60J1, 0RG60JJ, 0RG60K0, 0RG60K1, 0RG60KJ, 0RG60Z0, 0RG60Z1, 0RG60ZJ, 0RG6370, 0RG6371, 0RG637J, 0RG63J0, 0RG63J1, 0RG63JJ, 0RG63K0, 0RG63K1, 0RG63KJ, 0RG63Z0, 0RG63Z1, 0RG63ZJ, 0RG6470, 0RG6471, 0RG647J, 0RG64J0, 0RG64J1, 0RG64JJ, 0RG64K0, 0RG64K1, 0RG64KJ, 0RG64Z0, 0RG64Z1, 0RG64ZJ, 0RGA070, 0RGA071, 0RGA07J, 0RGA0J0, 0RGA0J1, 0RGA0JJ, 0RGA0K0, 0RGA0K1, 0RGA0KJ, 0RGA0Z0, 0RGA0Z1, 0RGA0ZJ, 0RGA370, 0RGA371, 0RGA37J, 0RGA3J0, 0RGA3J1, 0RGA3JJ, 0RGA3K0, 0RGA3K1, 0RGA3KJ, 0RGA3Z0, 0RGA3Z1, 0RGA3ZJ, 0RGA470, 0RGA471, 0RGA47J, 0RGA4J0, 0RGA4J1, 0RGA4JJ, 0RGA4K0, 0RGA4K1, 0RGA4KJ, 0RGA4Z0, 0RGA4Z1, 0RGA4ZJ, 0SG0070, 0SG0071, 0SG007J, 0SG00J0, 0SG00J1, 0SG00JJ, 0SG00K0, 0SG00K1, 0SG00KJ, 0SG00Z0, 0SG00Z1, 0SG00ZJ, 0SG0370, 0SG0371, 0SG037J, 0SG03J0, 0SG03J1, 0SG03JJ, 0SG03K0, 0SG03K1, 0SG03KJ, 0SG03Z0, 0SG03Z1, 0SG03ZJ, 0SG0470, 0SG0471, 0SG047J, 0SG04J0, 0SG04J1, 0SG04JJ, 0SG04K0, 0SG04K1, 0SG04KJ, 0SG04Z0, 0SG04Z1, 0SG04ZJ, 0SG3070, 0SG3071, 0SG307J, 0SG30J0, 0SG30J1, 0SG30JJ, 0SG30K0, 0SG30K1, 0SG30KJ, 0SG30Z0, 0SG30Z1, 0SG30ZJ, 0SG3370, 0SG3371, 0SG337J, 0SG33J0, 0SG33J1, 0SG33JJ, 0SG33K0, 0SG33K1, 0SG33KJ, 0SG33Z0, 0SG33Z1, 0SG33ZJ, 0SG3470, 0SG3471, 0SG347J, 0SG34J0, 0SG34J1, 0SG34JJ, 0SG34K0, 0SG34K1, 0SG34KJ, 0SG34Z0, 0SG34Z1, 0SG34ZJ, 0SG504Z, 0SG507Z, 0SG50JZ, 0SG50KZ, 0SG50ZZ, 0SG534Z, 0SG537Z, 0SG53JZ, 0SG53KZ, 0SG53ZZ, 0SG544Z, 0SG547Z, 0SG54JZ, 0SG54KZ, 0SG54ZZ0SG604Z, 0SG607Z, 0SG60JZ, 0SG60KZ, 0SG60ZZ, 0SG634Z, 0SG637Z, 0SG63JZ, 0SG63KZ, 0SG63ZZ, 0SG644Z, 0SG647Z, 0SG64JZ, 0SG64KZ, 0SG64ZZ, 0RG1070, 0RG10A0, 0RG10J0, 0RG10K0, 0RG10Z0, 0RG1370, 0RG13A0, 0RG13J0, 0RG13K00RG13Z0, 0RG1470, 0RG14A0, 0RG14J0, 0RG14K0, 0RG14Z0, 0RG2070, 0RG20J0, 0RG20K0, 0RG20Z0, 0RG2370, 0RG23A0, 0RG23J0, 0RG23K0, 0RG23Z0, 0RG2470, 0RG24A0, 0RG24J0, 0RG24K0, 0RG24Z0, 0RG4070, 0RG40A0, 0RG40J0, 0RG40K0, 0RG40Z0, 0RG4370, 0RG43A0, 0RG43J0, 0RG43K0, 0RG43Z0, 0RG4470, 0RG44A0, 0RG44J0, 0RG44K0, 0RG44Z0, 0RG1071, 0RG107J, 0RG10A1, 0RG10AJ, 0RG10J1, 0RG10JJ, 0RG10K1, 0RG10KJ, 0RG10Z1, 0RG10ZJ, 0RG1371, 0RG137J, 0RG13A1, 0RG13AJ, 0RG13J1, 0RG13JJ, 0RG13K1, 0RG13KJ, 0RG13Z1, 0RG13ZJ, 0RG1471, 0RG147J, 0RG14A1, 0RG14AJ, 0RG14J1, 0RG14JJ, 0RG14K1, 0RG14KJ, 0RG14Z1, 0RG14ZJ, 0RG2071, 0RG207J, 0RG20A1, 0RG20AJ, 0RG20J1, 0RG20JJ, 0RG20K1, 0RG20KJ, 0RG20Z1, 0RG2371, 0RG237J, 0RG23A1, 0RG23AJ, 0RG23J1, 0RG23JJ, 0RG23K1, 0RG23KJ, 0RG23Z1, 0RG23ZJ, 0RG2471, 0RG247J, 0RG24A1, 0RG24AJ, 0RG24J1, 0RG24JJ, 0RG24K1, 0RG24KJ, 0RG24Z1, 0RG24ZJ, 0RG4071, 0RG407J, 0RG40A1, 0RG40AJ, 0RG40J1, 0RG40JJ, 0RG40K1, 0RG40KJ, 0RG40Z1, 0RG40ZJ, 0RG4371, 0RG437J, 0RG43A1, 0RG43AJ, 0RG43J1, 0RG43JJ, 0RG43K1, 0RG43KJ, 0RG43Z1, 0RG43ZJ, 0RG4471, 0RG447J, 0RG44A1, 0RG44AJ, 0RG44J1, 0RG44JJ, 0RG44K1, 0RG44KJ, 0RG44Z1, 0RG44ZJ, 0RG6070, 0RG60A0, 0RG60J0, 0RG60K0, 0RG60Z0, 0RG6370, 0RG63A0, 0RG63J0, 0RG63K0, 0RG63Z0, 0RG6470, 0RG64A0, 0RG64J0, 0RG64K0, 0RG64Z0, 0RG70A0, 0RG7370, 0RG73A0, 0RG73K0, 0RG7470 0RG74A0, 0RG74J0, 0RG74K0, 0RG8070, 0RG80A0, 0RG80J0, 0RG80K0, 0RG8370, 0RG83A0, 0RG83J0, 0RG83K0, 0RG8470, 0RG84A0, 0RG84J0, 0RG84K0, 0RGA070, 0RGA0A0, 0RGA0J0, 0RGA0K0, 0RGA0Z0, 0RGA370, 0RGA3A0, 0RGA3J0, 0RGA3K0, 0RGA3Z0, 0RGA470, 0RGA4A0, 0RGA4J0, 0RGA4K0, 0RGA4Z0, 0RG6071, 0RG607J, 0RG60A1, 0RG60AJ, 0RG60J1, 0RG60JJ, 0RG60K1, 0RG60KJ, 0RG60Z1, 0RG60ZJ, 0RG6371, 0RG637J, 0RG63A1, 0RG63AJ, 0RG63J1, 0RG63JJ, 0RG63K1, 0RG63KJ, 0RG63Z1, 0RG63ZJ, 0RG6471, 0RG647J, 0RG64A1, 0RG64AJ, 0RG64J1, 0RG64JJ, 0RG64K1, 0RG64KJ, 0RG64Z1, 0RG64ZJ, 0RG7071, 0RG707J, 0RG70A1, 0RG70AJ, 0RG70J1, 0RG70JJ, 0RG70K1, 0RG70KJ, 0RG70Z1, 0RG70ZJ, 0RG7371, 0RG737J, 0RG73A1, 0RG73AJ, 0RG73J1, 0RG73JJ, 0RG73K1, 0RG73KJ, 0RG73Z1, 0RG73ZJ, 0RG7471, 0RG747J, 0RG74A1, 0RG74AJ, 0RG74J1, 0RG74JJ, 0RG74K1, 0RG74KJ, 0RG74Z1, 0RG74ZJ, 0RG8071, 0RG807J, 0RG80A1, 0RG80AJ, 0RG80J1, 0RG80JJ, 0RG80K1, 0RG80KJ, 0RG80Z1, 0RG80ZJ, 0RG8371, 0RG837J, 0RG83A1, 0RG83AJ, 0RG83J1, 0RG83JJ, 0RG83K1, 0RG83KJ, 0RG83Z1, 0RG83ZJ, 0RG8471, 0RG847J, 0RG84A1, 0RG84AJ, 0RG84J1, 0RG84JJ, 0RG84K1, 0RG84KJ, 0RG84Z1, 0RG84ZJ, 0RGA071, 0RGA07J, 0RGA0A1, 0RGA0AJ, 0RGA0J1, 0RGA0JJ, 0RGA0K1, 0RGA0KJ, 0RGA0Z1, 0RGA0ZJ, 0RGA371, 0RGA37J, 0RGA3A1, 0RGA3AJ, 0RGA3J1, 0RGA3JJ, 0RGA3K1, 0RGA3KJ, 0RGA3Z1, 0RGA3ZJ, 0RGA471, 0RGA47J, 0RGA4A1, 0RGA4AJ, 0RGA4J1, 0RGA4JJ, 0RGA4K1, 0RGA4KJ, 0RGA4Z1, 0RGA4ZJ, 0SG0070, 0SG00A0, 0SG00J0, 0SG00K0, 0SG00Z0, 0SG0370, 0SG03A0, 0SG03J0, 0SG03K0, 0SG03Z0, 0SG0470, 0SG04A0, 0SG04J0, 0SG04K0, 0SG04Z0, 0SG1070, 0SG10A0, 0SG10J0, 0SG10K0, 0SG10Z0, 0SG1370, 0SG13A0, 0SG13J0, 0SG13K0, 0SG13Z0, 0SG1470, 0SG14A0, 0SG14J0, 0SG14K0, 0SG14Z0, 0SG3070, 0SG30A0, 0SG30J0, 0SG30K0, 0SG30Z0, 0SG3370, 0SG33A0, 0SG33J0, 0SG33K0, 0SG33Z0, 0SG3470, 0SG34A0, 0SG34J0, 0SG34K0, 0SG34Z0, 0SG0071, 0SG00A1, 0SG00J1, 0SG00K1, 0SG00Z1, 0SG0371, 0SG03A1, 0SG03J1, 0SG03K1, 0SG03Z1, 0SG0471, 0SG04A1, 0SG04J1, 0SG04K1, 0SG04Z1, 0SG1071, 0SG10A1, 0SG10J1, 0SG10K1, 0SG10Z1, 0SG1371, 0SG13A1, 0SG13J1, 0SG34ZJ
    63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63180, 63182, 63185, 63190, 63191, 63194, 63195, 63196, 63197, 63198, 63199, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, S2350, S2351
    03.0, 03.01, 03.02,03.09, 03.3, 03.31,03.32, 03.39, 03.4,03.5, 03.51, 03.52,03.59, 03.6, 03.8,84.51, 84.52, 84.55,84.59, 84.8, 84.81, 84.82, 84.83, 84.84, 84.85
    00C30ZZ, 00C33ZZ, 00C34ZZ, 00CT0ZZ, 00CT3ZZ, 00CT4ZZ, 00CW0ZZ, 00CW3ZZ, 00CW4ZZ, 00CX0ZZ, 00CX3ZZ, 00CX4ZZ, 00CY0ZZ, 00CY3ZZ, 00CY4ZZ, 00JU0ZZ, 00JV0ZZ, 009T00Z, 009T0ZZ, 009T30Z, 009T3ZZ, 009T40Z, 009T4ZZ, 009U00Z, 009U0ZZ, 009W00Z, 009W0ZZ, 009W30Z, 009W3ZZ, 009W40Z, 009W4ZZ, 009X00Z, 009X0ZZ, 009X30Z, 009X3ZZ, 009X40Z, 009X4ZZ, 009Y00Z, 009Y0ZZ, 009Y30Z, 009Y3ZZ, 009Y40Z, 009Y4ZZ, 00JU0ZZ, 00JV0ZZ, 00NW0ZZ, 00NW3ZZ, 00NW4ZZ, 00NX0ZZ, 00NX3ZZ, 00NX4ZZ, 00NY0ZZ, 00NY3ZZ, 00NY4ZZ, 0RB00ZZ, 0RB03ZZ, 0RB04ZZ, 0RB10ZZ, 0RB13ZZ, 0RB14ZZ, 0RB40ZZ, 0RB43ZZ, 0RB44ZZ, 0RB60ZZ, 0RB63ZZ, 0RB64ZZ, 0RBA0ZZ, 0RBA3ZZ, 0RBA4ZZ, 0SB00ZZ, 0SB03ZZ, 0SB04ZZ, 0SB30ZZ, 0SB33ZZ, 0SB34ZZ, 0SB50ZZ, 0SB53ZZ, 0SB54ZZ, 0SB60ZZ, 0SB63ZZ, 0SB64ZZ, 0SB70ZZ, 0SB73ZZ, 0SB74ZZ, 0SB80ZZ, 0SB83ZZ, 0SB84ZZ, 009U30Z, 009U3ZZ, 009U40Z, 009U4ZZ, 009T0ZX, 009T3ZX, 009T4ZX, 009U0ZX, 009U3ZX, 009U4ZX, 009W0ZX, 009W3ZX, 009W4ZX, 009X0ZX, 009X3ZX, 009X4ZX, 009Y0ZX, 009Y3ZX, 009Y4ZX, 00BT0ZX, 00BT3ZX, 00BT4ZX, 00BW0ZX, 00BW3ZX, 00BW4ZX, 00BX0ZX, 00BX3ZX, 00BX4ZX, 00BY0ZX, 00BY3ZX, 00BY4ZX, 00JU3ZZ, 00JU4ZZ, 00JV3ZZ, 00JV4ZZ, 005T0ZZ, 005T3ZZ, 005T4ZZ, 005W0ZZ, 005W3ZZ, 005W4ZZ, 005X0Z Z, 005X3ZZ, 005X4ZZ, 005Y0ZZ, 005Y3Z, Z, 005Y4ZZ, 00BT0ZZ, 00BT3ZZ, 00BT4ZZ, 00BW0ZZ, 00BW3ZZ, 00BW4ZZ, 00BX0ZZ, 00BX3ZZ, 00BX4ZZ, 00BY0ZZ, 00BY3ZZ, 00BY4ZZ, 005T0ZZ, 005T3ZZ, 005T4ZZ, 00QT0ZZ, 00QT3ZZ, 00QT4ZZ, 00QW0ZZ, 00QW3ZZ, 00QW4ZZ, 00Q X0ZZ, 00QX3ZZ, 00QX4ZZ, 00QY0ZZ, 00QY3ZZ, 00QY4ZZ, 00NW0ZZ, 00NW3ZZ, 00NW4, ZZ, 00NX0ZZ, 00NX3ZZ, 00NX4ZZ, 00NY0ZZ, 00NY3ZZ, 00NY4ZZ, 3E0R3TZ, 3E0S3TZ, 0RG00A0, 0RG00A1, 0RG00AJ, 0RG03A0, 0RG03A1, 0RG03AJ, 0RG04A0, 0RG04A1, 0RG04AJ, 0RG10A0, 0RG10A1, 0RG10AJ, 0RG13A0, 0RG13A1, 0RG13AJ, 0RG14A0, 0RG14A1, 0RG14AJ, 0RG20A0, 0RG20A1, 0RG20AJ, 0RG23A0, 0RG23A1, 0RG23AJ, 0RG24A0, 0RG24A1, 0RG24AJ, 0RG40A0, 0RG40A1, 0RG40AJ, 0RG43A0, 0RG43A1, 0RG43AJ, 0RG44A0, 0RG44A1, 0RG44AJ, 0RG60A0, 0RG60A1, 0RG60AJ, 0RG63A0, 0RG63A1, 0RG63AJ, 0RG64A0, 0RG64A1, 0RG64AJ, 0RG70A0, 0RG70A1, 0RG70AJ, 0RG73A0, 0RG73A1, 0RG73AJ, 0RG74A0, 0RG74A1, 0RG74AJ, 0RG80A0, 0RG80A1 0RG80AJ, 0RG83A0, 0RG83A1, 0RG83AJ, 0RG84A0, 0RG84A1, 0RG84AJ, 0RGA0A0, 0RGA0A1, 0RGA0AJ, 0RGA3A0, 0RGA3A1, 0RGA3AJ, 0RGA4A0, 0RGA4A1, 0RGA4AJ, 0SG00A0, 0SG00A1, 0SG00AJ, 0SG03A0, 0SG03A1, 0SG03AJ, 0SG04A0, 0SG04A1, 0SG04AJ, 0SG10A0, 0SG10A1, 0SG10AJ, 0SG13A0, 0SG13A1 0SG13AJ, 0SG14A0, 0SG14A1, 0SG14AJ, 0SG30A0, 0SG30A1, 0SG30AJ, 0SG33A0 0SG33A1, 0SG33AJ, 0SG34A0, 0SG34A1, 0SG34AJ, 3E0U0GB, 3E0U3GB, 3E0V0GB,3E0V3GB, 3E0V3GC, 0RH00DZ, 0RH03DZ, 0RH04DZ, 0RH10DZ, 0RH13DZ, 0RH14DZ, 0RH40DZ, 0RH43DZ, 0RH44DZ, 0RH60DZ, 0RH63DZ, 0RH64DZ, 0RHA0DZ, 0RHA3DZ, 0RHA4DZ, 0RU00JZ, 0RU03JZ, 0RU04JZ, 0RU10JZ, 0RU13JZ, 0RU14JZ, 0RU40JZ, 0RU43JZ, 0RU44JZ, 0RU50JZ, 0RU53JZ, 0RU54JZ, 0RU60JZ, 0RU63JZ, 0RU64JZ, 0RUA0JZ, 0RUA3JZ, 0RUA4JZ, 0SH00DZ, 0SH03DZ, 0SH04DZ, 0SH30DZ, 0SH33DZ, 0SH34DZ, 0SU00JZ, 0SU03JZ, 0SU04JZ, 0SU30JZ, 0SU33JZ, 0SU34JZ, 0SU50JZ, 0SU53JZ, 0SU54JZ, 0SU60JZ, 0SU63JZ, 0SU64JZ, 0RH00BZ, 0RH03BZ, 0RH04BZ, 0RH10BZ, 0RH13BZ, 0RH14BZ, 0RH40BZ, 0RH43BZ, 0RH44BZ, 0RH60BZ, 0RH63BZ, 0RH64BZ, 0RHA0BZ, 0RHA3BZ, 0RHA4BZ, 0SH00BZ, 0SH03BZ, 0SH04BZ, 0SH30BZ, 0SH33BZ, 0SH34BZ, 0RW004Z, 0RW034Z, 0RW044Z, 0RW104Z, 0RW134Z, 0RW144Z, 0RW404Z, 0RW434Z, 0RW444Z, 0RW604Z, 0RW634Z, 0RW644Z, 0RWA04Z, 0RWA34Z, 0RWA44Z, 0SW004Z, 0SW034Z, 0SW044Z, 0SW304Z, 0SW334Z, 0SW344Z, 0RH00CZ, 0RH03CZ, 0RH04CZ, 0RH10CZ, 0RH13CZ, 0RH14CZ, 0RH40CZ, 0RH43CZ, 0RH44CZ, 0RH60CZ, 0RH63CZ, 0RH64CZ, 0RHA0CZ, 0RHA3CZ, 0RHA4CZ, 0SH00CZ, 0SH03CZ, 0SH04CZ, 0SH30CZ, 0SH33CZ, 0SH34CZ, 0RW004Z, 0RW034Z, 0RW044Z, 0RW104Z, 0RW134Z, 0RW144Z, 0RW404Z, 0RW434Z, 0RW444Z, 0RW604Z, 0RW634Z, 0RW644Z, 0RWA04Z, 0RWA34Z, 0RWA44Z, 0SW004Z, 0SW034Z, 0SW044Z, 0SW304Z, 0SW334Z, 0SW344Z, 0RH00DZ, 0RH03DZ, 0RH04DZ, 0RH10DZ, 0RH13DZ, 0RH14DZ, 0RH40DZ, 0RH43DZ, 0RH44DZ, 0RH60DZ, 0RH63DZ, 0RH64DZ, 0RHA0DZ, 0RHA3DZ, 0RHA4DZ, 0SH00DZ, 0SH03DZ, 0SH04DZ, 0SH30DZ, 0SH33DZ, 0SH34DZ, 0RW00JZ, 0RW03JZ, 0RW04JZ, 0RW10JZ, 0RW13JZ, 0RW14JZ, 0RW40JZ, 0RW43JZ, 0RW44JZ, 0RW60JZ, 0RW63JZ, 0RW64JZ, 0RWA0JZ, 0RWA3JZ, 0RWA4JZ, 0SW00JZ, 0SW03JZ, 0SW04JZ, 0SW30JZ, 0SW33JZ, 0SW34JZ
    22523, 22524, 22525, 22520, 22521, 22522, S2360
    81.66, 81.65
    0PS33ZZ, 0PS43ZZ, 0QS03ZZ, 0QS13ZZ, 0QSS3ZZ
    S2361, 22310, 22315, 22325, 22326, 22327, 22510 22512, 22513, 22514, 22515

    0PU33JZ, 0PU34JZ, 0PU43JZ, 0PU44JZ, 0QU03JZ, 0QU04JZ, 0QU13JZ, 0QU14JZ
    Epidural Injections
    62310, 62311, 64479, 64480, 64483, 64484

    Intentionally left blank – Listed CPT codes always require Prior Approval
    Facet Injections
    64490, 64491, 64492, 64493, 64494, 64495

    Intentionally left blank – Listed CPT codes always require Prior Approval
    Spinal Cord Stimulator
    0282T, 0283T, 0284T, 0285T, 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688
    03.93, 86.94, 86.95, 86.96, 86.97, 86.98
    00HU0MZ, 00HU3MZ, 00HU4MZ, 00HV0MZ, 00HV3MZ, 00HV4MZ, 0JH60BZ, 0JH63BZ, 0JH70BZ, 0JH73BZ, 0JH80BZ, 0JH83BZ, 0JH60DZ, 0JH63DZ, 0JH70DZ, 0JH73DZ, 0JH80DZ, 0JH83DZ, 0JH60MZ, 0JH63MZ, 0JH70MZ, 0JH73MZ, 0JH80MZ, 0JH83MZ, 0JH60CZ, 0JH63CZ, 0JH70CZ, 0JH73CZ, 0JH80CZ, 0JH83CZ, 0JH60EZ, 0JH63EZ, 0JH70EZ, 0JH73EZ, 0JH80EZ, 0JH83EZ
    Pain Pump
    62318, 62355, 62365 62319, 62360, 62350, 62361, 62351, 62362

    Please note,
    Pain Pumps are
    only eligible for
    coverage they
    when are billed in
    conjunction with the
    following diagnosis
    codes: 721.*-724.*,
    338.1, 338.2, 338.4
    07HK03Z, 07HK33Z, 07HK43Z, 07HL03Z, 07HL33Z, 07HL43Z, 07HM03Z, 07HM33Z, 07HM43Z, 07HN03Z, 07HN33Z, 07HN43Z, 07HP03Z, 07HP33Z, 07HP43Z, 0FH003Z, 0FH033Z, 0FH043Z, 0FH103Z, 0FH133Z, 0FH143Z, 0FH203Z, 0FH233Z, 0FH243Z, 0FH403Z, 0FH433Z, 0FH443Z, 0FHB03Z, 0FHB33Z, 0FHB43Z, 0FHB73Z, 0FHB83Z, 0FHD03Z, 0FHD33Z, 0FHD43Z, 0FHD73Z, 0FHD83Z, 0FHG03Z, 0FHG33Z, 0FHG43Z, 0JH60VZ, 0JH63VZ, 0JH70VZ, 0JH73VZ, 0JH80VZ, 0JH83VZ, 0JHD0VZ, 0JHD3VZ, 0JHF0VZ, 0JHF3VZ, 0JHG0VZ, 0JHG3VZ, 0JHH0VZ, 0JHH3VZ, 0JHL0VZ, 0JHL3VZ, 0JHM0VZ, 0JHM3VZ, 0JHN0VZ, 0JHN3VZ, 0JHP0VZ, 0JHP3VZ, 0JHS03Z, 0JHS33Z, 0JHT03Z, 0JHT0VZ, 0JHT33Z, 0JHT3VZ, 0JHV03Z, 0JHV33Z, 0JHW03Z, 0JHW33Z, 0RH003Z, 0RH033Z, 0RH043Z, 0RH103Z, 0RH133Z, 0RH143Z, 0RH303Z, 0RH333Z, 0RH343Z, 0RH403Z, 0RH433Z, 0RH443Z, 0RH503Z, 0RH533Z, 0RH543Z, 0RH603Z, 0RH633Z, 0RH643Z, 0RH903Z, 0RH933Z, 0RH943Z, 0RHA03Z, 0RHA33Z, 0RHA43Z, 0RHB03Z, 0RHB33Z, 0RHB43Z, 0RHE03Z, 0RHE33Z, 0RHE43Z, 0RHF03Z, 0RHF33Z, 0RHF43Z, 0RHG03Z, 0RHG33Z, 0RHG43Z, 0RHH03Z, 0RHH33Z, 0RHH43Z, 0RHJ03Z, 0RHJ33Z, 0RHJ43Z, 0RHK03Z, 0RHK33Z, 0RHK43Z, 0RHL03Z, 0RHL33Z, 0RHL43Z, 0RHM03Z, 0RHM33Z, 0RHM43Z, 0RHN03Z, 0RHN33Z, 0RHN43Z, 0RHP03Z, 0RHP33Z, 0RHP43Z, 0RHQ03Z, 0RHQ33Z, 0RHQ43Z, 0RHR03Z, 0RHR33Z, 0RHR43Z, 0RHS03Z, 0RHS33Z, 0RHS43Z, 0RHT03Z, 0RHT33Z, 0RHT43Z, 0RHU03Z, 0RHU33Z, 0RHU43Z, 0RHV03Z, 0RHV33Z, 0RHV43Z, 0RHW03Z, 0RHW33Z, 0RHW43Z, 0RHX03Z, 0RHX33Z, 0SHD33Z, 0SHD43Z, 0SHF03Z, 0SHF33Z, 0SHF43Z, 0SHG03Z, 0SHG33Z, 0SHG43Z, 0SHH03Z, 0SHH33Z, 0SHH43Z, 0SHJ03Z, 0SHJ33Z, 0SHJ43Z, 0SHK03Z, 0SHK33Z, 0SHK43Z, 0SHL03Z, 0SHL33Z, 0SHL43Z, 0SHM03Z, 0SHM33Z, 0SHM43Z, 0SHN03Z, 0SHN33Z, 0SHN43Z, 0SHP03Z, 0SHP33Z, 0SHP43Z, 0SHQ03Z, 0SHQ33Z, 0SHQ43Z, 0TH503Z, 0TH533Z, 0TH543Z, 0TH573Z, 0TH583Z, 0TH903Z, 0TH933Z, 0TH943Z, 0TH973Z, 0TH983Z, 0THB03Z, 0THB33Z, 0THB43Z, 0THB73Z, 0THB83Z, 0THD03Z, 0THD33Z, 0THD43Z, 0THD73Z, 0THD83Z, 0THDX3Z, 0UH303Z, 0UH333Z, 0UH343Z, 0UH803Z, 0UH833Z, 0UH843Z, 0UH873Z, 0UH883Z, 0VH403Z, 0VH433Z, 0VH443Z, 0VH473Z, 0VH483Z, 0VH803Z, 0VH833Z, 0VH843Z, 0VH873Z, 0VH883Z, 0VHD03Z, 0VHD33Z, 0VHD43Z, 0VHD73Z, 0VHD83Z, 0VHM03Z, 0VHM33Z, 0VHM43Z, 0VHM73Z, 0VHM83Z, 0VHR03Z, 0VHR33Z, 0VHR43Z, 0VHR73Z, 0VHR83Z, 0VHS03Z, 0VHS33Z, 0VHS43Z, 0VHSX3ZM47.011, M47.012, M47.013, M47.014, M47.015, M47.016, M47.019, M47.021, M47.022, M47.029, M50.20, M50.21, M50.22, M50.23, M51.26, M51.27, M51.24, M51.25, M51.9, M51.9, M51.44, M51.45, M51.46, M51.47, M51.9, M50.30, M50.31, M50.32, M50.33, M51.34, M51.35, M51.36, M51.37, M51.34, M51.35, M51.36, M51.37, M51.9, M50.00, M50.01, M50.02, M50.03, M51.04, M51.05, M51.06, M96.1, M96.1, M96.1, M96.1, M46.40, M46.48, M46.49, M51.9, M46.41, M46.42, M46.43, M50.10, M50.11, M50.12, M50.13, M50.80, M50.81, M50.82, M50.83, M50.90, M50.91, M50.92, M50.93, M46.44, M46.45, M51.84, M51.85, M46.46, M46.47, M51.86, M51.87, M48.01, M48.02, M48.03, M99.20, M99.21, M99.30, M99.31, M99.40, M99.41, M99.50 M99.51, M99.60, M99.61, M99.70, M99.71, M54.2, M53.0, M53.1, M54.11, M54.12, M54.13, M43.6, M54.00, M54.01, M54.02, M67.88, M53.81, M53.82, M53.83, M54.81, M53.82 M47.21, M47.22, M47.23, M47.811, M47.812, M47.813, M47.891, M47.892, M47.893, M47.11, M47.12, M47.13, M47.24, M47.25, M47.814, M47.815, M47.894, M47.895, M47.26, M47.27, M47.28, M47.816, M47.817, M47.818, M47.896, M47.897, M47.898, M47.14, M47.15, M47.16, M48.20, M48.21, M48.22, M48.23, M48.24, M48.25, M48.26, M48.27, M48.10, M48.11, M48.12, M48.13, M48.14, M48.15, M48.16, M48.17, M48.18, M48.19, M48.30, M48.31, M48.32, M48.33, M48.34, M48.35, M48.36, M48.37, M48.38, M25.78, M48.9, M47.20, M47.819, M47.899, M47.9, M47.10, M48.00, M48.04, M48.05, M99.22, M99.32, M99.42, M99.52, M99.62, M99.72, M48.06, M48.07, M99.23, M99.33, M99.43, M99.53, M99.63, M99.73, M48.00, M48.08, M99.24, M99.25, M99.26, M99.27, M99.28, M99.29, M99.34, M99.35, M99.36, M99.37, M99.38, M99.39, M99.44, M99.45, M99.46, M99.47, M99.48, M99.49, M99.54, M99.55, M99.56, M99.57, M99.58, M99.59, M99.64, M99.65, M99.66, M99.67, M99.68, M99.69, M99.74, M99.75, M99.76, M99.77, M99.78, M99.79, M54.6, M54.5, M54.30, M54.31, M54.32, M54.40, M54.41, M54.42, M51.14, M51.15, M51.16, M51.17, M54.14, M54.15, M54.16, M54.17, M54.5, M54.89, M54.9, M43.27, M43.28, M53.2X7, M53.2X8, M53.3, M53.86, M53.87, M53.88, M53.3, M53.2X8, M53.3, M54.03, M54.04, M54.05, M54.06, M54.07, M54.08, M54.09, M62.830, M43.20, M43.21, M43.22, M43.23, M43.24, M43.25, M43.26, M43.27, M43.28, M43.8X9, M53.80, M53.83, M53.84, M53.85, M53.9
    22818, 22819, 22855, 22856, 22857, 22861, 22862, 22864, 22865

    Intentionally left blank – Listed CPT codes always require Prior Approval

    *Includes all codes within range.

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    Glossary terms found on this page:

    Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.


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