Spinal Procedures Requiring Prior Authorization - Tufts Health Plan

Spine Procedure CodesRequiring Prior Authorization.Tufts Health Plan requires prior authorization with the Precertification Department for the following procedureswhen performed on an elective, non-emergent basis.ProcedureDescriptionCode22220 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical22224 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar225322253322548225542255622558Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace(other than for decompression); thoracicArthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace(other than for decompression); lumbarArthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or withoutexcision of odontoid processArthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace(other than for decompression); cervical below C2Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace(other than for decompression); thoracicArthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace(other than for decompression); lumbarNote: If requested, the use of recombinant bone morphogenic protein will be covered for thisprocedure code, for single level fusions between L2 and S1 only, when the criteria for thearthrodesis itself is met.22590 Arthrodesis, posterior technique, craniocervical (occiput-C2)22595 Arthrodesis, posterior technique, atlas-axis (C1-C2)22600 Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment226102261222630Arthrodesis, posterior or posterolateral technique, single level; thoracic (with or without lateraltransverse technique)Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateraltransverse technique)Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepareinterspace (other than for decompression), single interspace; lumbar22899 Unlisted procedure, spine62287Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebraldisk, any method, single or multiple levels, lumbar (e.g., manual or automated percutaneousdiscectomy, percutaneous laser discectomy)Originated 02/2008, Revised 01/2010 1 of 2 Tufts Health Plan-Spine Services Requiring Prior Authorization

6300163003630056301263015630166301763020630306304063042630456304663047630556305663064Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina,without facetectomy, foraminotomy or discectomy, (e.g., spinal stenosis), one or two vertebralsegments; cervicalLaminectomy with exploration and/or decompression of spinal cord and/or cauda equina,without facetectomy, foraminotomy or discectomy, (e.g., spinal stenosis), one or two vertebralsegments; thoracicLaminectomy with exploration and/or decompression of spinal cord and/or cauda equina,without facetectomy, foraminotomy or discectomy, (e.g., spinal stenosis), one or two vertebralsegments; lumbar, except for spondylolisthesisLaminectomy with removal of abnormal facets and/or pars inter-articularis with decompressionof cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina,without facetectomy, foraminotomy or discectomy, (e.g., spinal stenosis), more than 2 vertebralsegments; cervicalLaminectomy with exploration and/or decompression of spinal cord and/or cauda equina,without facetectomy, foraminotomy or discectomy, (e.g., spinal stenosis), more than 2 vertebralsegments; thoracicLaminectomy with exploration and/or decompression of spinal cord and/or cauda equina,without facetectomy, foraminotomy or discectomy, (e.g., spinal stenosis), more than 2 vertebralsegments; lumbarLaminotomy (hemilaminectomy), with decompression of nerve root(s), including partialfacetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace,cervicalLaminotomy (hemilaminectomy), with decompression of nerve root(s), including partialfacetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace,lumbar (including open or endoscopically-assisted approach)Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partialfacetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, singleinterspace; cervicalLaminotomy (hemilaminectomy), with decompression of nerve root(s), including partialfacetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, singleinterspace; lumbarLaminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression ofspinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)), singlevertebral segment; cervicalLaminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression ofspinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)), singlevertebral segment; thoracicLaminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression ofspinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)), singlevertebral segment; lumbarTranspedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g.,herniated intervertebral disk), single segment; thoracicTranspedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g.,herniated intervertebral disk), single segment; lumbar (including transfacet, or lateralextraforaminal approach) (e.g., far lateral herniated intervertebral disc)Costovertebral approach with decompression of spinal cord or nerve root(s), (e.g., herniatedintervertebral disk), thoracic; single segmentOriginated 02/2008, Revised 01/2010 2 of 2 Tufts Health Plan-Spine Services Requiring Prior Authorization