Prior authorization required for listed CPT/HCPCS procedure codes

Request prior authorization when submitting procedure codes that map to policy-listed CPT/HCPCS codes so coverage can be determined against the medical necessity criteria. The policy lists supported and not‑supported codes (e.g., CPT 62287; CPT 22867‑22870, 62330‑62331; HCPCS S2350, S2351, C1821, S2348) that require prior review to confirm medical necessity.

• Prior authorization should be requested for codes in CPT Code Table 1 and CPT/HCPCS Code Tables that the policy maps to procedures.
• Authorization allows the Health Plan to determine whether the submitted procedure meets the policy's medical necessity criteria.

Align submitted CPT coding with policy tables and recent updates

Ensure coding aligns with the Health Plan's policy tables and recent code updates: the policy added CPT codes 62330 and 62331 to the list of CPT Codes That Do Not Support Coverage Criteria — code selection must reflect the actual procedure to allow correct coverage determination.

• When using CPT 62287, specify the exact procedure performed because the code encompasses various disc procedures and not all are considered medically necessary.
• Confirm whether CPT 62330 and 62331 are billed; these codes are listed in the policy as not supporting coverage criteria.

Conservative therapy required (PT/home exercise, activity modification, analgesic or ESI)

Document completion of required conservative therapy before surgical coverage is considered for many presentations: at minimum ≥ four weeks of physical therapy or prescribed home exercise program and ≥ four weeks of activity modification plus either NSAID/acetaminophen for ≥ three weeks (unless contraindicated) or an epidural steroid injection, unless severe motor deficit is present.

• Conservative therapy requirement applies to Pathway 1.b.ii and Pathway 2 failure criteria.
• Documented inability to tolerate conservative therapy can substitute for completed therapy when applicable.

Provide requested documentation during review and prior authorization processes

Follow all policy documentation and authorization instructions exactly; provide any additional clinical information requested during review to support coverage determination.

• If the Health Plan requests clarification or additional documentation during prior authorization or claim adjudication, respond with the requested material to avoid delays.

Required documentation: age, diagnosis, imaging, MRC scores, and conservative therapy

Include explicit documentation showing member age ≥ 18, diagnosis of herniated lumbar disc, imaging confirming nerve‑root compression, MRC muscle strength scores, and records of required conservative therapy (duration/content) or documentation of inability to tolerate; when CPT 62287 is used, state the exact procedure performed.

• Age and diagnosis: document member is ≥ 18 and has a herniated lumbar disc.
• Imaging: include imaging reports confirming nerve root compression.
• MRC scores: record the Medical Research Council 0–5 muscle strength scale score (e.g., ≤3 or 4 as specified in criteria).
• Conservative therapy: document dates/duration and content (PT/home exercise, activity modification, NSAID/acetaminophen or epidural steroid injection) or inability to tolerate.
• For CPT 62287: specify the exact procedure to determine medical necessity.

Billing risk for codes in 'Do Not Support' tables (denial or extra review)

Billing procedures using CPT/HCPCS codes listed in the policy's 'Do Not Support' tables (for example CPT 22867‑22870, 62330‑62331; HCPCS C1821, S2348) may be denied or subjected to additional review if clinical criteria are not met or the procedure is one of the minimally invasive techniques listed as not supported.

• Use caution when submitting claims for codes in CPT Code Table 2 and HCPCS Code Table 2; these are identified as not supporting coverage criteria.
• Denial risk increases when documentation does not meet the policy's medical necessity pathways.

Coverage decisions depend on EOC/contract and applicable state/federal rules

Coverage determinations are subject to the member's Evidence of Coverage, policy/contract terms, and applicable state or federal requirements; state Medicaid or Medicare NCDs/LCDs take precedence where they conflict with this clinical policy.

• Verify coverage against the member's specific plan documents (EOC, certificate of coverage, contract).
• For Medicaid or Medicare members, review state Medicaid manuals and any applicable NCDs/LCDs prior to applying this policy.

Documentation and policy precedence: follow EOC/contract; NCD/LCD precedence

Follow the Health Plan's Evidence of Coverage and contract terms when seeking authorization or submitting claims; where state Medicaid rules or Medicare NCDs/LCDs apply, those determinations take precedence over this clinical policy.

• When plan documents conflict with this clinical policy, the terms of the coverage documents and applicable law govern.
• Review CMS NCDs/LCDs and state Medicaid guidance for Medicare/Medicaid members before applying the policy criteria.