Medical Specialty Solutions - Musculoskeletal Surgery (Spine) Utilization Review Matrix 2024 Form

Fidelis Care Utilization Review Matrix 2024 Musculoskeletal Surgery (Spine) CERVICAL SPINE SURGERY PROCEDURES Procedure Name Primary CPT Code Allowable Billed Groupings Additional Covered Procedures/Codes Ancillary Procedures/Codes Authorization is provided at the procedure level. There are multiple CPT codes that can be associated with each procedure. These are assumed to be part of the primary request and, when completed in combination, do not require a separate authorization. These codes do not require prior authorization. If the main procedure is approved, these codes are understood to be included and do not require precertification from the health plan. *Please note: This is not an all-inclusive list of every possible ancillary code Cervical Anterior Decompression (without fusion) 63075 63075, +63076 Vertebral Corpectomy: 63081, +63082, 63300, 63304, +63308 Instrumentation: +22859 Vertebral Corpectomy: 63081, +63082, 63300, 63304, +63308 Instrumentation: +22845, 22853, 22854 Bone Grafts: +20930, +20931, +20936, +20937, +20938 Cervical ACDF - Anterior Cervical Decompression with Fusion - Single Level 22551 22548, 22551, 22554 Decompression: 63075, +63076 Removal of Artificial Disc: 22864 Cervical ACDF - Anterior Cervical Decompression with Fusion - Multiple Levels 22552 +22552, +22585 Decompression: 63075, +63076 Single-Level ACDF: 22548, 22551, 22554 Removal of Artificial Disc: 22864 Vertebral Corpectomy: 63081, +63082, 63300, 63304, +63308 Instrumentation: +22845, +22846, 22853, 22854 Bone Grafts: 20930, +20931, +20936, +20937, +20938 Bone Marrow Aspiration: 20939 1 – Fidelis Care (NY) – Spine Utilization Review Matrix 2024

CERVICAL SPINE SURGERY PROCEDURES Procedure Name Primary CPT Code Allowable Billed Groupings Additional Covered Procedures/Codes Ancillary Procedures/Codes Authorization is provided at the procedure level. There are multiple CPT codes that can be associated with each procedure. These are assumed to be part of the primary request and, when completed in combination, do not require a separate authorization. These codes do not require prior authorization. If the main procedure is approved, these codes are understood to be included and do not require precertification from the health plan. *Please note: This is not an all-inclusive list of every possible ancillary code Cervical Posterior Decompression (without fusion) 63045 63001, 63015, 63020, +63035, 63040, +63043, 63045, +63048, 63050, 63051 Cervical Posterior Decompression with Fusion - Single Level 22600 22590, 22595, 22600 Decompression: 63001, 63015, 63020, +63035, 63040, +63043, 63045, +63048, 63050, 63051 Decompression: 63001, 63015, 63020, +63035, 63040, +63043, 63045, +63048, 63050, 63051 Single-Level Fusion: 22590, 22595, 22600 Removal of Artificial Disc: 22864 Instrumentation: +22840, +22841 Bone Grafts: +20930, +20931, +20936, +20937 Instrumentation: +22840, +22841, +22842, +22843, +22844 Bone Grafts: +20930, +20931, +20936, +20937 Instrumentation: 22845, 22853 Bone Grafts: +20930, +20931, +20936, +20937, +20938 Instrumentation: 22845, 22853 Bone Grafts: +20930, +20931, +20936, +20937, +20938 Cervical Posterior Decompression with Fusion - Multiple Levels 22595 22595, +22614 Cervical Artificial Disc - Single Level 22856 22856, 22861 Cervical Artificial Disc - Two Levels 22858 +22858, +0098T, +0095T Single-Level Artificial Disc: 22856, 22861 Removal of Artificial Disc: 22864 2 – Fidelis Care (NY) – Spine - Utilization Review Matrix 2024

LUMBAR SPINE SURGERY PROCEDURES Procedure Name Primary CPT Code Allowable Billed Groupings Additional Covered Procedures/Codes Ancillary Procedures/Codes Authorization is provided at the procedure level. There are multiple CPT codes that can be associated with each procedure. These are assumed to be part of the primary request and, when completed in combination, do not require a separate authorization. These codes do not require prior authorization. If the main procedure is approved, these codes are understood to be included and do not require precertification from the health plan. *Please note: This is not an all-inclusive list of every possible ancillary code Lumbar Microdiscectomy 63030 62380, 63030, +63035 Lumbar Decompression 63047 63005, 63012, 63017, 63042, +63044, 63047, +63048, 63056, +63057 Microdiscectomy: 62380, 63030, +63035 Lumbar Fusion - Single Level 22612 22533, 22558, 22612, 22630, 22633, +63052, +63053 Microdiscectomy: 62380, 63030, +63035 Decompression: 63005, 63012, 63017, 63042, +63044, 63047, +63048, 63056, +63057 Instrumentation: +22840, +22841, +22842, +22845, +22853 Bone Grafts: +20930, +20931, +20936, +20937, +20938 Bone Marrow Aspiration: 20939 Lumbar Fusion - Multiple Levels 22614 +22534, +22585, +22614, +22632, +22634, +63052, +63053 Microdiscectomy: 62380, 63030, +63035 Decompression: 63005, 63012, 63017, 63042, +63044, 63047, +63048, 63056, +63057 Single Level Fusion: 22533, 22558, 22612, 22630, 22633 Instrumentation: +22840, +22841, +22842, +22845, +22853 Bone Grafts: +20930, +20931, +20936, +20937, +20938 Bone Marrow Aspiration: 20939 Lumbar Artificial Disc - Single Level 22857 22857, 22862, 22865 Lumbar Artificial Disc - Multiple Levels 22860 22860, +0164T, +0165T Single-Level Artificial Disc: 22857, 22862, 22865 3 – Fidelis Care (NY) – Spine - Utilization Review Matrix 2024

LUMBAR SPINE SURGERY PROCEDURES Procedure Name Primary CPT Code Allowable Billed Groupings Additional Covered Procedures/Codes Ancillary Procedures/Codes Authorization is provided at the procedure level. There are multiple CPT codes that can be associated with each procedure. These are assumed to be part of the primary request and, when completed in combination, do not require a separate authorization. These codes do not require prior authorization. If the main procedure is approved, these codes are understood to be included and do not require precertification from the health plan. *Please note: This is not an all-inclusive list of every possible ancillary code Sacroiliac Joint Fusion 27279 27279  Payment for procedures is contingent on the patient’s eligibility and plan limitations, if any, at the time the service is delivered.
 Musculoskeletal surgery services rendered through the Emergency Department are not managed by NIA.
 NIA does not prior authorize or manage the facility precertification for musculoskeletal surgery services.
Add-on codes (+) do not require separate authorization and are to be used in conjunction with approved primary code for the service rendered o Exception: multiple level add-on codes require an authorization for multiple level procedures 4 – Fidelis Care (NY) – Spine - Utilization Review Matrix 2024