Spine Surgery and Pain Management Procedure Therapy Prior Approval List

CPT

Description

Status

Comments

DECOMPRESSION SURGERY

63001

LAM W/O FACETEC FORAMOT/DSKC 1/2 VRT SEG CRV

Existing Code

 

63003

LAMINECTOMY W/O FFD 1/2 VERT SEG THORACIC

Existing Code

 

63005

LAMINECTOMY W/O FFD 1/2 VERT SEG LUMBAR

Existing Code

 

63011

LAMINECTOMY W/O FFD 1/2 VERT SEG SACRAL

Existing Code

 

63012

LAMINECTOMY W/RMVL ABNORMAL FACETS LUMBAR

Existing Code

 

63015

LAMINECTOMY W/O FFD > 2 VERT SEG CERVICAL

Existing Code

 

63016

LAMINECTOMY W/O FFD > 2 VERT SEG THORACIC

Existing Code

 

63017

LAMINECTOMY W/O FFD > 2 VERT SEG LUMBAR

Existing Code

 

63020

LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC CERVC

Existing Code

 

63030

LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC LUMBR

Existing Code

 

63035

LAMNOTMY W/DCMPRSN NRV EACH ADDL CRVCL/LMBR

Existing Code

 

63040

LAMOT PRTL FFD EXC DISC REEXPL 1 NTRSPC CERVICAL

Existing Code

 

63042

LAMOT PRTL FFD EXC DISC REEXPL 1 NTRSPC LUMBAR

Existing Code

 

63043

LAMOT PRTL FFD EXC DISC REEXPL 1 NTRSPC EA CRV

Existing Code

 

63044

LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC EA LMBR

Existing Code

 

63045

LAM FACETECTOMY & FORAMOTOMY 1 SEGMENT CERVICAL

Existing Code

 

63046

LAM FACETECTOMY & FORAMOTOMY 1 SEGMENT THORACIC

Existing Code

 

63047

LAM FACETECTOMY & FORAMOTOMY 1 SEGMENT LUMBAR

Existing Code

 

63048

LAM FACETECTOMY&FORAMTOMY 1 SGM EA CRV THRC/LMBR

Existing Code

 

63050

LAMOP CERVICAL W/DCMPRN SPI CORD 2/> VERT SEG

Existing Code

 

63051

LAMOPLASTY CERVICAL DCMPRN CORD 2/> SEG RCNSTJ

Existing Code

 

63055

TRANSPEDICULAR DCMPRN SPINAL CORD 1 SEG THORACIC

Existing Code

 

63056

TRANSPEDICULAR DCMPRN SPINAL CORD 1 SEG LUMBAR

Existing Code

 

63057

TRANSPEDICULAR DCMPRN 1 SEG EA THORACIC/LUMBAR

Existing Code

 

63064

COSTOVERTEBRAL DCMPRN SPINAL CORD THORACIC 1 SEG

Existing Code

 

63066

COSTOVERTEBRAL DCMPRN SPINE CORD THORACIC EA SEG

Existing Code

 

63075

DISCECTOMY ANT DCMPRN CORD CERVICAL 1 NTRSPC

Existing Code

 

63076

DISCECTOMY ANT DCMPRN CORD CERVICAL EA NTRSPC

Existing Code

 

63077

DISCECTOMY ANT DCMPRN CORD THORACIC 1 NTRSPC

Existing Code

 

63078

DISCECTOMY ANT DCMPRN CORD THORACIC EA NTRSPC

Existing Code

 

63081

VERTEBRAL CORPECTOMY ANT DCMPRN CERVICAL 1 SEG

Existing Code

 

63082

VERTEBRAL CORPECTOMY DCMPRN CERVICAL EA SEG

Existing Code

 

63085

VERTEBRAL CORPECTOMY DCMPRN CORD THORACIC 1 SEG

Existing Code

 

63086

VERTEBRAL CORPECTOMY DCMPRN CORD THORACIC EA SEG

Existing Code

 

63087

VCRPEC THORACOLMBR DCMPRN LWR THRC/LMBR 1 SEG

Existing Code

 

63088

VCRPEC THORACOLMBR DCMPRN LWR THRC/LMBR EA SEG

Existing Code

 

63090

VCRPEC TRANSPRTL/RPR DCMPRN THRC LMBR/SAC 1 SEG

Existing Code

 

63091

VCRPEC TRANSPRTL/RPR DCMPRN THRC LMBR/SAC EA SEG

Existing Code

 

63101

VERTEB CORPECT LAT XTRCAVITARY DCMPRN THRC 1 SEG

Existing Code

 

63102

VERTEB CORPECT LAT XTRCAVITARY DCMPRN LMBR 1 SEG

Existing Code

 

63103

VCRPEC LAT XTRCAVITARY DCMPRN THRC/LMBR EA SEG

Existing Code

 

63170

LAM W/MYELOTOMY CERVICAL/THORACIC/THORACOLUMBAR

Existing Code

 

63172

LAM W/DRG INTRMEDULLARY CYST/SYRINX SUBARACHNOID

Existing Code

 

63173

LAM W/DRG INTRMEDULRY CYST/SYRINX PRTL/PLEURAL

Existing Code

 

63180

LAM&SCTJ DENTATE LIG W/WO DURAL GRF CRV 1/2 SEG

Existing Code

 

63182

LAM&SCTJ DENTATE LIG W/WO DURAL GRF CRV >2 SEG

Existing Code

 

63185

LAMINECTOMY W/RHIZOTOMY 1/2 SEGMENTS

Existing Code

 

63190

LAMINECTOMY W/RHIZOTOMY > 2 SEGMENTS

Existing Code

 

63191

LAMINECTOMY W/SECTION SPINAL ACCESSORY NERVE

Existing Code

 

63194

LAM CORDOTOMY SCTJ 1 SPINOTHALMIC TRACT CERVICAL

Existing Code

 

63195

LAM CORDOTOMY SCTJ 1 SPINOTHALMIC TRACT THORACIC

Existing Code

 

63196

LAM CORDOTOMY SCTJ BOTH SPINOTHALMIC TRACTS CRV

Existing Code

 

63197

LAM CORDOTOMY SCTJ BOTH SPINOTHALMIC TRACT THRC

Existing Code

 

63198

LAM CORDOTOMY SCTJ BOTH TRACTS 2 STAGES CERVICAL

Existing Code

 

63199

LAM CORDOTOMY SCTJ BOTH TRACTS 2 STAGES THORACIC

Existing Code

 

63200

LAMINECTOMY RELEASE TETHERED SPINAL CORD LUMBAR

Existing Code

 

63250

LAM EXC/OCCLUSION AVM SPINAL CORD CERVICAL

Existing Code

 

63251

LAM EXC/OCCLUSION AVM SPINAL CORD THORACIC

Existing Code

 

63252

LAM EXC/OCCLUSION AVM SPI CORD THORACOLUMBAR

Existing Code

 

63265

LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL CERVICAL

Existing Code

 

63266

LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL THORACIC

Existing Code

 

63267

LAM EXC/EVAC ISPI LESION OTH/THN NEO XDRL LUMBAR

Existing Code

 

63268

LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL SACRAL

Existing Code

 

63270

LAM EXC ISPI LES OTH/THN NEO IDRL CERVICAL

Existing Code

 

63271

LAM EXC ISPI LES OTH/THN NEO IDRL THORACIC

Existing Code

 

63272

LAM EXC ISPI LES OTH/THN NEO IDRL LUMBAR

Existing Code

 

63273

LAM EXC ISPI LES OTH/THN NEO IDRL SACRAL

Existing Code

 

63275

LAMINECTOMY BX/EXC ISPI NEO XDRL CERVICAL

Existing Code

 

63276

LAMINECTOMY BX/EXC ISPI NEO XDRL THORACIC

Existing Code

 

63277

LAMINECTOMY BX/EXC ISPI NEO XDRL LUMBAR

Existing Code

 

63278

LAMINECTOMY BX/EXC ISPI NEO XDRL SACRAL

Existing Code

 

63280

LAM BX/EXC ISPI NEO IDRL XMED CERVICAL

Existing Code

 

63281

LAM BX/EXC ISPI NEO IDRL XMED THORACIC

Existing Code

 

63282

LAM BX/EXC ISPI NEO IDRL XMED LUMBAR

Existing Code

 

63283

LAM BX/EXC ISPI NEO IDRL SACRAL

Existing Code

 

63285

LAM BX/EXC ISPI NEO IDRL IMED CERVICAL

Existing Code

 

63286

LAM BX/EXC ISPI NEO IDRL IMED THORACIC

Existing Code

 

63287

LAM BX/EXC ISPI NEO IDRL IMED THORACOLMBR

Existing Code

 

63290

LAM BX/EXC ISPI NEO XDRL-IDRL LES ANY LVL

Existing Code

 

63295

OSTPL RCNSTJ DORSAL SPI ELMNTS FLWG ISPI PX

Existing Code

 

63300

VCRPEC LES 1 SGM XDRL CERVICAL

Existing Code

 

63301

VCRPEC LES 1 SGM XDRL THORACIC TTHRC

Existing Code

 

63302

VCRPEC LES 1 SEG XDRL THRC THORACOLMBR

Existing Code

 

63303

VCRPEC LES 1 SEG XDRL LMBR/SAC TRANSPRTL/RPR

Existing Code

 

63304

VERTEBRAL CORPECTOMY EXC LES 1 SEG IDRL CERVICAL

Existing Code

 

63305

VERTEBRAL CORPECTOMY LES 1 SEG IDRL THRC TTHRC

Existing Code

 

63306

VERTEBRL CORPECT LES 1 SEG IDRL THRC THORACOLMBR

Existing Code

 

63307

VCRPEC LES 1 SEG IDRL LMBR/SAC TRANSPRTL/RPR

Existing Code

 

63308

VERTEBRAL CORPECTOMY EXC INDRL LES EACH SEG

Existing Code

 

S2350

DISKECT ANT W/OSTEOPHYTECT; LUMBAR 1 INTERSPACE

Existing Code

 

S2351

DISKECT ANT W/OSTEOPHYTECT; LUMB EA ADD INTRSP

Existing Code

 

EPIDURAL INJECTIONS

64479

NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC 1 LVL

Existing Code

 

64480

NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC EA LVL

Existing Code

 

64483

NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL

Existing Code

 

64484

NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC EA LVL

Existing Code

 

FACETS INJECTIONS

64490

NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL

Existing Code

 

64491

NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL

Existing Code

 

64492

NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL

Existing Code

 

64493

NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL

Existing Code

 

64494

NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL

Existing Code

 

64495

NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL

Existing Code

 

KYPHOPLASTY

22521

PERCUT VERTEBROPLASTY LUMB

Existing Code

 

22522

PERCUT VERTEBROPLASTY ADDL

Existing Code

 

22523

PERCUT KYPHOPLASTY THOR

Existing Code

 

22524

PERCUT KYPHOPLASTY LUMBAR

Existing Code

 

22525

PERCUT KYPHOPLASTY ADD-ON

Existing Code

 

S2360

PERQ VERTPLSTY 1 VERT BDY UNILAT/BILAT INJ; CERV

Existing Code

 

OTHER

22818

KYPHECTOMY SINGLE OR TWO SEGMENTS

Existing Code

 

22819

KYPHECTOMY 3 OR MORE SEGMENTS

Existing Code

 

22855

REMOVAL ANTERIOR INSTRUMENTATION

Existing Code

 

22856

TOT DISC ARTHRP ART DISC ANT APPRO 1 NTRSPC CRV

Existing Code

 

22857

TOT DISC ARTHRP ART DISC ANT APPRO 1 NTRSPC LMBR

Existing Code

 

22861

REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC CRV

Existing Code

 

22862

REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC LMBR

Existing Code

 

22864

RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE CERVICAL

Existing Code

 

22865

RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE LUMBAR

Existing Code

 

PAIN PUMP

62350

IMPLTJ REVJ/RPSG ITHCL/EDRL CATH PMP W/O LAM

Existing Code

 

62351

IMPLTJ REVJ/RPSG ITHCL/EDRL CATH W/LAM

Existing Code

 

62355

REMOVE SPINAL CANAL CATHETER

Existing Code

 

62360

IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS SUBQ RSVR

Existing Code

 

62361

IMPLTJ/RPLCMT FS NON-PRGRBL PUMP

Existing Code

 

62362

IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS PRGRBL PUMP

Existing Code

 

62365

REMOVE SPINE INFUSION DEVICE

Existing Code

 

SPINAL CORD STIMULATOR

63650

PRQ IMPLTJ NSTIM ELECTRODE ARRAY EPIDURAL

Existing Code

Dorsal root ganglion (DRG) stimulation is not considered medically necessary due to insufficient evidence of therapeutic value.

63655

LAM IMPLTJ NSTIM ELTRDS PLATE/PADDLE EDRL

Existing Code

Dorsal root ganglion (DRG) stimulation is not considered medically necessary due to insufficient evidence of therapeutic value.

63661

RMVL SPINAL NSTIM ELTRD PRQ ARRAY INCL FLUOR

Existing Code

Dorsal root ganglion (DRG) stimulation is not considered medically necessary due to insufficient evidence of therapeutic value.

63662

RMVL SPINAL NSTIM ELTRD PLATE/PADDLE INCL FLUOR

Existing Code

Dorsal root ganglion (DRG) stimulation is not considered medically necessary due to insufficient evidence of therapeutic value.

63663

REVJ INCL RPLCMT NSTIM ELTRD PRQ RA INCL FLUOR

Existing Code

Dorsal root ganglion (DRG) stimulation is not considered medically necessary due to insufficient evidence of therapeutic value.

63664

REVJ INCL RPLCMT NSTIM ELTRD PLT/PDLE INCL FLUOR

Existing Code

Dorsal root ganglion (DRG) stimulation is not considered medically necessary due to insufficient evidence of therapeutic value.

63685

INSJ/RPLCMT SPI NPGR DIR/INDUXIVE COUPLING

Existing Code

Dorsal root ganglion (DRG) stimulation is not considered medically necessary due to insufficient evidence of therapeutic value.

63688

REVJ/RMVL IMPLANTED SPINAL NEUROSTIM GENERATOR

Existing Code

Dorsal root ganglion (DRG) stimulation is not considered medically necessary due to insufficient evidence of therapeutic value.

SPINAL FUSION

22532

ARTHRODESIS LATERAL EXTRACAVITARY THORACIC

Existing Code

 

22533

ARTHRODESIS LATERAL EXTRACAVITARY LUMBAR

Existing Code

 

22534

ARTHRODESIS LAT EXTRACAVITARY EA ADDL THRC/LMBR

Existing Code

 

22548

ARTHRD ANT TRANSORL/XTRORAL C1-C2 W/WO EXC ODNTD

Existing Code

 

22551

ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C2

Existing Code

 

22552

ARTHRD ANT INTERDY CERVCL BELW C2 EA ADDL NTRSPC

Existing Code

 

22554

ARTHRD ANT MIN DISCECT INTERBODY CERV BELOW C2

Existing Code

 

22556

ARTHRD ANT MIN DISCECTOMY INTERBODY THORACIC

Existing Code

 

22558

ARTHRODESIS ANTERIOR INTERBODY LUMBAR

Existing Code

 

22585

ARTHRODESIS ANTERIOR INTERBODY EA ADDL NTRSPC

Existing Code

 

22586

ARTHRODESIS PRESACRAL INTRBDY W/INSTRUMENT L5-S1

Existing Code

 

22590

ARTHRODESIS POSTERIOR CRANIOCERVICAL

Existing Code

 

22595

ARTHRODESIS POSTERIOR ATLAS-AXIS C1-C2

Existing Code

 

22600

ARTHRODESIS PST/PSTLAT CERVICAL BELW C2 SGM

Existing Code

 

22610

ARTHRODESIS POSTERIOR/POSTEROLATERAL THORACIC

Existing Code

 

22612

ARTHRODESIS POSTERIOR/POSTEROLATERAL LUMBAR

Existing Code

 

22614

ARTHRODESIS POSTERIOR/POSTEROLATERAL EA ADDL

Existing Code

 

22630

ARTHRODESIS POSTERIOR INTERBODY LUMBAR

Existing Code

 

22632

ARTHRODESIS POSTERIOR INTERBODY EA ADDL

Existing Code

 

22633

ARTHDSIS POST/POSTEROLATRL/POSTINTERBODY LUMBAR

Existing Code

 

22634

ARTHDSIS POST/POSTERLATRL/POSTINTRBDYADL SPC/SEG

Existing Code

 

22800

ARTHRODESIS POSTERIOR SPINAL DFRM UP 6 VRT SEG

Existing Code

 

22802

ARTHRODESIS POSTERIOR SPINAL DFRM 7-12 VRT SEG

Existing Code

 

22804

ARTHRODESIS POSTERIOR SPINAL DFRM 13/> VRT SEG

Existing Code

 

22808

ARTHRODESIS ANTERIOR SPINAL DFRM 2-3 VRT SEG

Existing Code

 

22810

ARTHRODESIS ANTERIOR SPINAL DFRM 4-7 VRT SEG

Existing Code

 

22812

ARTHRODESIS POSTERIOR SPINAL DFRM 8/> VRT SEG

Existing Code

 

22830

EXPLORATION SPINAL FUSION

Existing Code

 

22840

POSTERIOR NON-SEGMENTAL INSTRUMENTATION

Existing Code

 

22841

INTERNAL SPINAL FIXATION WIRING SPINOUS PROCESS

Existing Code

 

22842

POSTERIOR SEGMENTAL INSTRUMENTATION 3-6 VRT SEG

Existing Code

 

22843

POSTERIOR SEGMENTAL INSTRUMENTATION 7-12 VRT SEG

Existing Code

 

22844

POSTERIOR SEGMENTAL INSTRUMENTATION 13/> VRT SE

Existing Code

 

22845

ANTERIOR INSTRUMENTATION 2-3 VERTEBRAL SEGMENTS

Existing Code

 

22846

ANTERIOR INSTRUMENTATION 4-7 VERTEBRAL SEGMENTS

Existing Code

 

22847

ANTERIOR INSTRUMENTATION 8/> VERTEBRAL SEGMENTS

Existing Code

 

22848

PELVIC FIXATION OTHER THAN SACRUM

Existing Code

 

22849

REINSERTION SPINAL FIXATION DEVICE

Existing Code

 

22850

REMOVAL POSTERIOR NONSEGMENTAL INSTRUMENTATION

Existing Code

 

22852

REMOVAL POSTERIOR SEGMENTAL INSTRUMENTATION

Existing Code

 

0195T

ARTHRODESIS PRESACRAL INTRBDY W/O INSTRUM L5/S1

Existing Code

 

0196T

ARTHRODESIS PRESACRAL INTRBDY W/O INSTRUM L4/L5

Existing Code

 

VERTEBROPLASTY

22310

TREAT SPINE FRACTURE

Existing Code

 

22315

TREAT SPINE FRACTURE

Existing Code

 

22325

TREAT SPINE FRACTURE

Existing Code

 

22326

TREAT NECK SPINE FRACTURE

Existing Code

 

22327

TREAT THORAX SPINE FRACTURE

Existing Code

 

22510

PERQ VERTEBROPLASTY UNI/BI INJX CERVICOTHORACIC

Existing Code

 

22512

VERTEBROPLASTY EACH ADDL CERVICOTHOR/LUMBOSACRAL

Existing Code

 

22513

PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULATION

Existing Code

 

22514

PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ LMBR

Existing Code

 

22515

PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ EACH

Existing Code