Spinal Interventional Pain Management and Lumbar Spine Surgery Policy Number: Original Effective Date: MM.06.024 01/01/2014 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 10/23/2015 Section: Surgery; Medicine Place(s) of Service: Office; Outpatient; Inpatient I. The following spinal interventional pain management and lumbar spine surgery procedures require precertification through National Imaging Associates, Inc. (NIA): A. Therapeutic spinal epidural injections or select nerve root blocks: 1. Caudal 2. Interlaminar 3. Transforaminal B. Paravertebral facet joint denervation (radiofrequency neurolysis) C. Paravertebral facet joint injections or blocks D. Lumbar fusion surgery E. Lumbar decompression (laminectomy, facetectomy and foraminotomy) F. Lumbar microdiscectomy G. Sacroiliac joint injections II. Administrative Guidelines A. The ordering physician can obtain precertification or consult with NIA by accessing their website at http://www.radmd.com/ or by calling 1 (866) 306-9729, from 6 a.m. to 6 p.m., weekdays, Hawaii Time. Refer to the e-library for instructions on navigating the radmd.com website (RadMD Get Started) and requesting precertification/checking the status of a request (RadMD QuickStart). B. For access to the latest clinical guidelines used for precertification, go to www.radmd.com and click on the link entitled View Clinical Guidelines. C. For interventional pain management procedures (epidural injections, facet joint denervation neurolysis, facet joint injections and sacroiliac joint injections), if more than one procedure is planned, a separate precertification number must be obtained for each procedure planned.
Spinal Interventional Pain Management and Lumbar Spine Surgery 2 D. For spinal surgeries (lumbar fusions, lumbar decompressions, and lumbar microdiscectomy), one precertification number should be obtained for the most invasive surgery to be performed. E. Precertification requirements for injection procedures apply only to office and outpatient services (POS 11, 22, or 24). Services performed in connection with an emergency department visit or observation room confinement (POS 23) and services rendered during an inpatient stay (POS 21) do not require precertification. F. Precertification is not required for services ordered for FEP members. G. Codes that require precertification: 1. Spinal epidural injections: Cervical Thoracic Region 0228T 0229T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level each additional level (List separately in addition to code for primary procedure) 62310 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic 64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level 64480 cervical or thoracic, each additional level (List separately in addition to code for Lumbar Sacral Region 0230T 0231T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level each additional level (List separately in addition to code for primary procedure) 62311 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) 64483 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with
Spinal Interventional Pain Management and Lumbar Spine Surgery 3 imaging guidance (fluoroscopy or CT); lumbar or sacral, single level 64484 lumbar or sacral, each additional level (List separately in addition to code for 2. Paravertebral facet joint denervation (radiofrequency neurolysis): Cervical thoracic region 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint 64634 cervical or thoracic, each additional facet joint (List separately in addition to code for Lumbar sacral region 64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint 64636 lumbar or sacral, each additional facet joint (List separately in addition to code for 3. Paravertebral facet joint injections or blocks: Cervical thoracic region 0213T 0214T 0215T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level second level (List separately in addition to code for third and any additional level(s) (List separately in addition to code for 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level 64491 second level (List separately in addition to code for 64492 third and any additional level(s) (List separately in addition to code for
Spinal Interventional Pain Management and Lumbar Spine Surgery 4 Lumbar sacral region 0216T 0217T 0218T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level second level (List separately in addition to code for third and any additional level(s) (List separately in addition to code for 64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 64494 second level (List separately in addition to code for 64495 third and any additional level(s) (List separately in addition to code for 4. Sacroiliac joint injections: 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed HCPCS Code G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography (this code is to be billed by facilities only) 5. Lumbar spinal fusion surgery: Lumbar Fusion (single level) 22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar 22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) 22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar
Spinal Interventional Pain Management and Lumbar Spine Surgery 5 22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar ICD-10-PCS 0SG0071, 0SG00A1, 0SG00J1, 0SG00K1, 0SG00Z1 0SG0371, 0SG03A1, 0SG03J1, 0SG03K1, 0SG03Z1 0SG0471, 0SG04A1, 0SG04J1, 0SG04K1, 0SG04Z1 0SG1071, 0SG10A1, 0SG10J1, 0SG10K1, 0SG10Z1 0SG1371, 0SG13A1, 0SG13J1, 0SG13K1, 0SG13Z1 0SG1471, 0SG14A1, 0SG14J1, 0SG14K1, 0SG14Z1 0SG3071, 0SG30A1, 0SG30J1, 0SG30K1, 0SG30Z1 0SG3371, 0SG33A1, 0SG33J1, 0SG33K1, 0SG33Z1 0SG3471, 0SG34A1, 0SG34J1, 0SG34K1, 0SG34Z1 Fusion of lumbar vertebral joint, posterior approach, posterior column, open approach, code by device Fusion of lumbar vertebral joint, posterior approach, posterior column, percutaneous approach, code by device Fusion of lumbar vertebral joint, posterior approach, posterior column, percutaneous endoscopic approach, code by device Fusion of lumbar vertebral joints, posterior approach, posterior column, open approach, code by device Fusion of 2 or more lumbar vertebral joints, posterior approach, posterior column, percutaneous approach, code by device Fusion of 2 or more lumbar vertebral joints, posterior approach, posterior column, percutaneous endoscopic approach, code by device Fusion of lumbosacral joint, posterior approach, posterior column, open approach, code by device Fusion of lumbosacral joint, posterior approach, posterior column, percutaneous approach, code by device Fusion of lumbosacral joint, posterior approach, posterior column, percutaneous endoscopic approach, code by device Lumbar Fusion (multiple levels) 22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar 22534 thoracic or lumbar, each additional vertebral segment (List separately in addition to code for 22558 Arthrodesis, anterior interbody technique, including minimal discectomy to
Spinal Interventional Pain Management and Lumbar Spine Surgery 6 prepare interspace (other than for decompression); lumbar 22585 each additional interspace (List separately in addition to code for primary procedure) 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) 22614 each additional vertebral segment (List separately in addition to code for primary (procedure) 22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar 22632 each additional interspace (List separately in addition to code for (primary procedure) 22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar 22634 each additional interspace and segment (List separately in addition to code for Lumbar Decompression 63005 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis 63012 Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) 63017 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 vertebral segments; lumbar 63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar 63035 each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure 63042 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar 63044 each additional lumbar interspace (List separately in addition to code for
Spinal Interventional Pain Management and Lumbar Spine Surgery 7 63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; lumbar 63048 each additional segment, cervical, thoracic, or lumbar 63056 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (e.g., far lateral herniated intervertebral disc) 63057 each additional segment, thoracic or lumbar (List separately in addition to code for ICD-10-PCS 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 Drainage of spinal meninges, open approach, code by device Drainage of spinal meninges, percutaneous approach, code by device Drainage of spinal meninges, endoscopic approach, code by device Drainage of spinal canal, open approach, code by device Drainage of cervical spinal cord, open approach, code by device Drainage of cervical spinal cord, percutaneous approach, code by device Drainage of cervical spinal cord, percutaneous endoscopic approach, code by device Drainage of thoracic spinal cord, open approach, code by device Drainage of thoracic spinal cord, percutaneous approach, code by device Drainage of thoracic spinal cord, percutaneous endoscopic approach, code by device Drainage of lumbar spinal cord, open approach, code by device Drainage of lumbar spinal cord, percutaneous approach, code by device Drainage of lumbar spinal cord, percutaneous endoscopic approach, code by device Inspection, open approach, code by body part (spinal canal or cord)
Spinal Interventional Pain Management and Lumbar Spine Surgery 8 00NW0ZZ, 00NW3ZZ, 00NW4ZZ 00NX0ZZ, 00NX3ZZ, 00NX4ZZ 00NY0ZZ, 00NY3ZZ, 00NY4ZZ 0RB00ZZ, 0RB03ZZ, 0RB04ZZ 0RB10ZZ, 0RB13ZZ, 0RB14ZZ 0RB30ZZ, 0RB33ZZ, 0RB34ZZ 0RB40ZZ, 0RB43ZZ, 0RB44ZZ 0RB50ZZ, 0RB53ZZ, 0RB54ZZ 0RB60ZZ, 0RB63ZZ, 0RB64ZZ 0RB90ZZ, 0RB93ZZ, 0RB94ZZ 0RBA0ZZ, 0RBA3ZZ, 0RBA4ZZ 0RBB0ZZ, 0RBB3ZZ, 0RBB4ZZ 0RT30ZZ, 0RT40ZZ, 0RT50ZZ, 0RT90ZZ, 0RTB0ZZ 0SB00ZZ, 0SB03ZZ, 0SB04ZZ 0SB20ZZ, 0SB23ZZ, 0SB24ZZ 0SB30ZZ, 0SB33ZZ, 0SB34ZZ 0SB40ZZ, 0SB43ZZ, 0SB44ZZ 0SB50ZZ, 0SB53ZZ, Release cervical spinal cord, code by approach Release thoracic spinal cord, code by approach Release lumbar spinal cord, code by approach Excision of occipital-cervical joint, code by approach Excision of cervical vertebral joint, code by approach Excision of cervical vertebral disc, code by approach Excision of cervicothoracic vertebral joint, code by approach Excision of cervicothoracic vertebral disc, code by approach Excision of thoracic vertebral joint, code by approach Excision of thoracic vertebral disc, code by approach Excision of thoracolumbar vertebral joint, code by approach Excision of thoracolumbar vertebral disc, code by approach Resection, code by body part (cervical vertebral disc, cervicothoracic vertebral joint, cervicothoracic vertebral disc, thoracic vertebral disc, or thoracolumbar vertebral disc) Excision of lumbar vertebral joint, code by approach Excision of lumbar vertebral disc, code by approach Excision of lumbosacral joint, code by approach Excision of lumbosacral disc, code by approach Excision of sacrococcygeal joint, code by approach
Spinal Interventional Pain Management and Lumbar Spine Surgery 9 0SB54ZZ 0SB60ZZ, 0SB63ZZ, 0SB64ZZ 0SB70ZZ, 0SB73ZZ, 0SB74ZZ 0SB80ZZ, 0SB83ZZ, 0SB84ZZ 0ST20ZZ, 0ST40ZZ Excision of coccygeal joint, code by approach Excision of right sacroiliac joint, code by approach Excision of left sacroiliac joint, code by approach Excision, open approach, code by body part (lumbar vertebral or lumbosacral disc) Lumbar Microdiscectomy 63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar 63035 each additional interspace, cervical or lumbar (List separately in addition to code for ICD-10-PCS 0RB30ZZ, 0RB33ZZ, 0RB34ZZ 0RB50ZZ, 0RB53ZZ, 0RB54ZZ 0RB90ZZ, 0RB93ZZ, 0RB94ZZ 0RBB0ZZ, 0RBB3ZZ, 0RBB4ZZ 0RT30ZZ, 0RT40ZZ, 0RT50ZZ, 0RT90ZZ, 0RTB0ZZ 0SB20ZZ, 0SB23ZZ, 0SB24ZZ 0SB40ZZ, 0SB43ZZ, 0SB44ZZ 0ST20ZZ, 0ST40ZZ Excision of cervical vertebral disc, code by approach Excision of cervicothoracic vertebral disc, code by approach Excision of thoracic vertebral disc, code by approach Excision of thoracolumbar vertebral disc, code by approach Resection, open approach, code by body part (cervical vertebral disc, cervicothoracic vertebral joint, cervicothoracic vertebral disc, thoracic vertebral disc, or thoracolumbar vertebral disc) Excision of lumbar vertebral disc, code by approach Excision of lumbosacral disc, code by approach Resection, open approach, code by body part (cervical vertebral disc, cervicothoracic vertebral joint, cervicothoracic vertebral disc, thoracic vertebral disc, or thoracolumbar vertebral disc)
Spinal Interventional Pain Management and Lumbar Spine Surgery 10 III. Limitations Lumbar artificial disc replacement and pre-sacral fusion are not covered due to a lack of published studies showing that these procedures improve health outcomes over current standard therapies. Codes representing these procedures include the following: A. Lumbar artificial disc replacement 0163T 0165T 0221T 0222T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional space interspace, lumbar (List separately in addition to code for Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar each additional vertebral segment (list separately in addition to code for 22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar 22862 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar 22865 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar B. Pre-Sacral Fusion 0195T 0196T 0309T Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L5-S1 interspace L4-L5 interspace (List separately in addition to code for primary procedure) Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (List separately in addition to code for the
Spinal Interventional Pain Management and Lumbar Spine Surgery 11 22586 Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace