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Medical Policy Musculoskeletal Services Management
Policy Number: 220 BCBSA Reference Number: N/A Effective Date: April 1, 2023

Related Policies Musculoskeletal Services Management CPT and HCPCS Codes, #221 Medicare Advantage Management, #132 Outpatient Prior Authorization Code List, #072 Artificial Intervertebral Disc - Lumbar Spine, #592 Decompression of the Intervertebral Disc Using Laser Energy or Radiofrequency Coblation Nucleoplasty,

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Diagnosis and Treatment of Sacroiliac Joint Pain, #320 Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures, #498 Intraosseous Basivertebral Nerve Ablation, #485 Manipulation under Anesthesia, #483 Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation, #482 Sacral Nerve Neuromodulation-Stimulation, #153 Table of Contents Overview ....................................................................................................................................................... 1 Policy and Coverage Criteria for Commercial and Medicare Advantage Products ...................................... 2 Requesting Prior Authorization Information .................................................................................................. 3 List of Retired Musculoskeletal Services Medical Policies ........................................................................... 3 Policy History ................................................................................................................................................ 4 Disclaimer...................................................................................................................................................... 4

Overview
Effective April 1, 2023, we will be updating our prior authorization requirements for inpatient and outpatient pre-scheduled musculoskeletal services, such as spine, joint, and pain management procedures.

With this authorization program in place, we can help ensure that services are medically appropriate for treating the member’s condition. Authorization Manager helps to efficiently streamline this process.

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These changes apply to our commercial (HMO, PPO) and Medicare Advantage members. Commercial indemnity is excluded.
Policy and Coverage Criteria for Commercial and Medicare Advantage Products InterQual® includes medical necessity criteria for the following musculoskeletal services:

InterQual Subsets Anterior Cervical Discectomy and Fusion (ACDF) Arthrodesis, Ankle (Talotibial Joint) Arthroscopy or Arthroscopically Assisted Surgery, Knee Arthroscopy or Arthroscopically Assisted Surgery, Shoulder Arthroscopy or Arthroscopically Assisted Surgery, Shoulder (Adolescent) Arthroscopy, Diagnostic, +/- Synovial Biopsy, Hip Arthroscopy, Diagnostic, +/- Synovial Biopsy, Knee Arthroscopy, Surgical Ankle Arthroscopy, Surgical, Hip Arthrotomy, Hip Arthrotomy, Knee Arthrotomy, Shoulder Artificial Disc Replacement, Cervical Decompression +/- Fusion, Cervical Decompression +/- Fusion, Lumbar Decompression +/- Fusion, Thoracic Discectomy, Percutaneous, Lumbar Discography, Spine, Lumbar Epidural or Intrathecal Catheter Placement Epidural Steriod Injections Facet Joint Injections Fusion (with Laminectomy), Cervical Fusion (with Laminectomy), Lumbar Fusion (with Laminectomy), Thoracic Fusion, Cervical Spine Fusion, Lumbar Spine Fusion, Thoracic Spine Hemiarthroplasty, Hip Hemilaminectomy (Laminotomy) +/- Discectomy, Cervical Hemilaminectomy (Laminotomy) +/- Discectomy, Lumbar Joint Replacement, Shoulder Laminectomy (with Fusion), Cervical Laminectomy (with Fusion), Lumbar Laminectomy (with Fusion), Thoracic Laminectomy, Cervical Laminectomy, Lumbar Laminectomy, Thoracic Manipulation Under Anesthesia, Shoulder Neuroablation, Percutaneous
Removal and Replacement, Total Joint Replacement (TJR), Hip Removal and Replacement, Total Joint Replacement (TJR), Knee Removal and Replacement, Total Joint Replacement (TJR), Shoulder Sacroiliac (SI) Joint Injection Scoliosis or Kyphosis Surgery Spinal Cord Stimulator (SCS) Insertion Sympathetic Blockade

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Total Joint Replacement (TJR), Ankle Total Joint Replacement, Hip Total Joint Replacement, Knee Unicondylar or Patellofemoral Knee Replacement Vertebroplasty or Kyphoplasty

Requesting Prior Authorization Information Providers will need to use Authorization Manager to submit initial authorization requests for musculoskeletal services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, check existing case status, and view/print the decision letter. For commercial members, your requests must meet InterQual® criteria and our medical policy guidelines. Requests for Medicare Advantage members must adhere to CMS guidelines.

To ensure your request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

For more helpful tips, see our Authorization Manager User Guide.

Resources • Refer to our Authorization Manager page for tips, guides, and video demonstrations. List of Retired Musculoskeletal Services Medical Policies The following musculoskeletal medical policies will be retired effective April 1, 2023. As of this date, these policies will no longer be available on the Blue Cross website. Use Authorization Manager to submit initial authorization requests for these musculoskeletal services.

For the list of codes that will require prior authorization, see Musculoskeletal Services Management Program CPT and HCPCS Codes, #221.

Retired Medical Policies Policy No. Artificial Intervertebral Disc - Cervical Spine 585 Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
retired effective March 1, 2025
111 Meniscal Allografts and Other Meniscal Implants retired effective March 1, 2025 110 Epidural Steroid Injections 690 Facet Joint Denervation 140 Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty and Mechanical Vertebral Augmentation 485 Percutaneous Vertebroplasty and Sacroplasty 484 Spinal Cord and Dorsal Root Ganglion Stimulation 472 Total Ankle Replacement 193

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Policy History Date Action 3/2025 Policy clarified. MP 111 Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions noted as retired. Codes 27415, 27416, 29866 29867 from retired MP 111 added to MP 221 Musculoskeletal Services Management CPT and HCPCS Codes. Code 28446 will no longer require prior authorization effective 3.1.25. This is a covered service. Effective 3/1/2025. Policy clarified. MP 110 Meniscal Allografts and Other Meniscal Implants noted as retired. Code 29868 from retired MP 110 added to MP 221 Musculoskeletal Services Management CPT and HCPCS Codes. Ongoing investigational code G0428 transferred to MP 400 Non-covered Services List. Effective 3/1/2025.

5/2024 Policy clarified. Related policies section updated to add musculoskeletal policies.
5/2023 Policy clarified. Policy 320 Diagnosis and Treatment of Sacroiliac Joint Pain removed from retired policies list. Policy 320 reactivated in May 2023 to reinstate policy statements on minimally invasive fixation/fusion of the sacroiliac joint.
Policy statements on anesthetic injection for diagnosing SIJ pain and corticosteroid injection for treatment of SIJ pain remain retired. 4/2023 InterQual Program document issued 4/2023. Effective 4/1/2023. Disclaimer
Coverage is subject to applicable benefit contract. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Member’s medical records must document that services are medically necessary for the care provided. Blue Cross Blue Shield of Massachusetts maintains the right to audit the services provided to our members, regardless of the participation status of the provider. All documentation must be available upon request. Failure to produce the requested information may result in denial or retraction of payment.