Spinal Procedures Requiring Prior Authorization - Tufts Health Plan

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