Provider Manual

Chapter 12: EmblemHealth Spine Surgery and Pain Management Therapies Program

This chapter contains policies and procedures for the EmblemHealth Spine Surgery and Pain Management Therapies Program:

  • Place of service for select spine surgery and interventional pain management therapy procedures
  • Program inclusion and exclusions
  • ICD-10 Procedure/Diagnosis Codes
  • Prior approval procedures
  • Grievance and appeal process

The EmblemHealth Spine Surgery and Pain Management Therapies Program is managed by OrthoNet, LLC and requires providers to contact OrthoNet directly to obtain prior approval for select spine surgery and interventional pain management therapy procedures.

For services provided on or after November 16, 2015, a prior approval is required for all codes defined in the Spine Surgery and Pain Management Procedure Therapy Code table, when performed in the following settings:

  • Practitioner’s office (POS 11)
  • Outpatient hospital setting (POS 22)
  • Inpatient hospital (POS 21)
  • Ambulatory surgery center (POS 24)


Affected Networks

The EmblemHealth Spine Surgery and Pain Management Therapies Program will apply to members* who participate in benefit plans associated with the following networks:

  • Prime Network
  • Enhanced Care Prime Network
  • Select Care Network

Which procedures require prior approval by OrthoNet?

Refer to the Spine Surgery and Pain Management Procedure Therapy Codes section for the list of codes that apply require prior approval. These codes are subject to change.


Does this program require referrals?

The EmblemHealth Spine Surgery and Pain Management Therapies Program does not require referrals. Prior approval is required for any service or procedure included in the code list. However, most plans do require a referral to access network specialists. Providers are reminded to verify member eligibility and benefits, and ensure there is a valid referral on file prior to the patient’s appointment.


How do providers request prior approval from OrthoNet?

To request prior approval, providers must complete and fax the correct OrthoNet EmblemHealth Prior Authorization Request form for the services being requested along with any supporting clinical notes, including relevant clinical history, imaging reports and other pertinent clinical information to: 1-844-296-4440.


What information do providers need to submit?

1. Complete the fax request form and make sure to include the following information when submitting requests:

  • Provider Information section: of the fax request form, include either the facility name or the treating provider name along with the corresponding NPI or Tax ID number.
  • To identify offices with multiple locations, please provide the full address of the location where the member will be treated.
  • Member Information section: provide the member’s name, date of birth and the EmblemHealth member identification number.
  • Request Information section: please complete all fields including:
    • Diagnosis code(s)
    • Requested procedure
    • Spinal level
    • Service setting*
    • Anticipated date of service

*Please note - OrthoNet will also review for appropriateness of location.

2. Fax the completed request form along with any supporting clinical information to OrthoNet at 1-844-296-4440.

Only prior approval request forms and any associated documents should be faxed to this number.


What documentation will OrthoNet need to render a decision?

OrthoNet will need sufficiently detailed, patient-specific clinical information to make a decision. This will include, at minimum, a relevant patient history that includes any prior treatments for this condition(s) including surgery, pain management, etc. Also required are copies of reports of significant imaging, such as MRI, CT, plain films and copies of relevant electro-diagnostic studies, if they have been performed. A proposed treatment plan/description of the proposed surgery, including the use of any implants is also essential. While a list of possible CPT-4 codes can be submitted, it is far more preferable to provide a written statement of the proposed clinical procedure(s). It is important to include a contact telephone number and fax number with the submission. This will help expedite any requests for additional information.


How long will it take to obtain prior approval?

For pre-service requests, it is OrthoNet’s goal to review the supporting clinical data, verify eligibility/ benefits, render a determination and assign an authorization number, if approved, within one (1) to two (2) business days following the receipt of all necessary information. All utilization management decisions will meet accreditation (NCQA) and regulatory time frames. Providers will be notified and given the following information, both verbally and via fax:

  • Authorization number
  • Number of approved visits and/or units
  • Next review date

For procedures performed at locations other than the clinician’s office, OrthoNet will also notify the facility.


Who reviews the prior approval requests?

All prior approval requests will be reviewed for medical necessity by a licensed health care professional who has received additional training in his/her specialty and who is supported by board certified MDs and DOs.


How do providers file requests for continued pain management therapy services?

Complete an OrthoNet EmblemHealth Pain Management Fax Request form and fax it to OrthoNet at 1-844-296-4440. For questions, contact OrthoNet’s Customer Service Department at 1-844-730-8503, Monday through Friday, 8:30 a.m. to 5:30 p.m.


Is it possible to check the status of a prior approval request?

To check on the status of a prior approval request, providers may contact OrthoNet’s Customer Service Department at 1-844-730-8503, Monday through Friday, 8:30 am to 5:30 pm. Once a determination has been made providers will be notified, both verbally and via fax, on the day the decision is made.

Please note: An authorization is not a guarantee of payment and it is contingent upon the member’s benefits, contract limitations and eligibility at the time of service.


Can providers still request prior approval from EmblemHealth?

No. Providers may not submit requests through Requestors will be directed to contact OrthoNet.


How long will the prior approval be valid?

Prior approvals are valid for 90 days from the date they are issued.


Where can I find the OrthoNet Prior Authorization Fax Request form?

The OrthoNet Prior Authorization Fax Request form can be downloaded from or the Provider Toolkit at Providers may also call OrthoNet Provider Services at 1-844-730-8503 to request forms.


Where do I send my claims?

OrthoNet has only been engaged to oversee utilization management. Providers should continue to submit claims to EmblemHealth. Instructions for submitting claims are available in the Claims chapter.

Note: Claims submitted without the required prior approval will be denied.


How do providers request a peer-to-peer review?

For Commercial and Medicaid members, providers may ask for a reconsideration or peer-to-peer discussion upon receipt of the notice of a denial of service from OrthoNet. Providers may also contact OrthoNet’s Customer Service department at 1-844-730-8503.

For Medicare members, providers may request a peer -to-peer discussion, but the decision cannot be changed. However, providers may request a “Re-Open,” which must be submitted in writing to OrthoNet with the additional clinical information the provider would like OrthoNet to review. Written requests must be faxed to OrthoNet at 1-844-296-4440.


How do providers file an appeal?

All commercial and Medicaid member appeals will be reviewed by OrthoNet. If a provider still disagrees with the decision, the provider may exercise his/her rights as outlined in the adverse determination notice. For Medicare, the member, or practitioner on behalf of the member, may file a clinical appeal with EmblemHealth in accordance with the instructions that accompany the denial.


Where do providers send appeals?

A prior approval request that is denied by OrthoNet for spine surgery and pain management therapies may be appealed through OrthoNet. Provider appeals should be mailed to OrthoNet at the following address:


EmblemHealth Appeals

P.O. Box 5046

White Plains, NY 10602-5046

Fax: 1-844-296-4440


Where can providers find more information?

For additional information, contact OrthoNet directly using one of the options provided below. To ask additional questions, you may sign in to use the Message Center at Select “General Information” from the drop down menu on the “Ask a Question” page.

EmblemHealth Spine Surgery and Pain Management Therapies Program Guide

Key Contact Information

OrthoNet Customer Service
(844) 730-8503
OrthoNet Fax Number
(844) 296-4440
OrthoNet website


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
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.

To request prior approval, providers must complete and fax the correct OrthoNet EmblemHealth Prior Authorization Request form for the services being requested along with any supporting clinical notes, including relevant clinical history, imaging reports and other pertinent clinical information to: 1-844-296-4440.

Members whose care is managed by Montefiore Medical Group (CMO) or HealthCare Partners (HCP) must contact the applicable organization for prior approval. Check the member’s ID card or eligibility information on to determine whether HIP, CMO, or HCP is the managing entity responsible for managing a member’s care; if HIP is the managing entity, then OrthoNet is the organization to contact for prior approval.