Effective 11/1/2025, this policy will be updated to include Fully-Funded Commercial Products. All other Commercial Products, including Self-Funded, will be addressed in the Prior Authorization via Web Based Tool for Procedures policy.
As a result of this updated expansion, several CPT codes will have prior authorization added for Commercial Products.
The CPT codes identified below in the following policies will be addressed in this Prior Authorization of Spinal Procedures policy and the Prior Authorization via Web Based Tool for Procedures policy, and the following policies will be archived:
- Artificial Intervertebral Disc Insertion Lumbar Spine
- CPT Codes 22857, 22860, 22862, 0165T
- Axial Lumbosacral Interbody Fusion
- CPT Code 22586
- Electrical Bone Growth Stimulation of the Appendicular Skeleton
- CPT Code 20975
- HCPCS Code E0749 changing to Covered for Commercial Products
- Interspinous Interlaminar Stabilization Distraction Devices Spacers
- CPT Codes 22867, 22868, 22869, 22870
- HCPCS Code C1821 changing to Covered for Commercial Products
The select CPT codes identified below in the following policies will be addressed in the Prior Authorization of Spinal Procedures and Prior Authorization via Web Based Tool for Procedures policies. However, these policies continue to address other services and will not be archived.
- Diagnosis and Treatment of SI Joint Pain
- CPT Codes 27278 and 27279
- Image Guided Minimally Invasive Spinal Decompression for Spinal Stenosis
- CPT Codes 0274T and 0275T
- New Technology and Miscellaneous Services
- CPT Codes 0095T, 0098T, 0164T, 0165T
In addition:
- Prior authorization will be removed from HCPCS code C9757 for Medicare Advantage Plans and Commercial Products, and
- Prior authorization will be added to CPT Codes 22585, 22840 and 27280 for Medicare Advantage Plans.
For additional details related to this policy, please click here.