CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Musculoskeletal Surgery (Spine) — Authorization and Included CPT Groupings

Defines which spine surgical procedures and associated CPT codes are considered part of a primary authorized musculoskeletal surgery for Blue Cross Blue Shield - South Carolina and which ancillary/add-on codes do not require separate prior authorization. Applies to providers submitting authorization requests for spine surgery.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyMusculoskeletal Surgery (Spine) — Authorization and Included CPT Groupings

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for the primary spine surgical procedure; associated ancillary and add-on codes billed with an approved primary procedure generally do not require separate authorization (except multiple-level add-ons).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleprimary CPT groupings listed

add-onadd-on codes included with approval

includedancillary codes included

exceptionadd-on authorization exception

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Authorization-dependent coverage

Covered when ALL of the following are met

Primary procedure authorized: The primary spine surgical procedure has prior authorization from the plan.

Authorization is required for the primary surgery request; multiple CPTs associated with that procedure are assumed included and do not require separate authorization.

Associated CPTs billed in conjunction: CPT codes listed as allowable billed groupings, additional covered procedures, or ancillary procedures are billed in conjunction with the approved primary code.

These associated and ancillary codes do not require separate authorization when included with the approved primary procedure (add-on codes are used in conjunction with an approved primary code).

Plan eligibility at time of service: Patient is eligible and plan limitations do not exclude coverage at time of service.

Payment is contingent on patient eligibility and plan limitations at the time the service is delivered; musculoskeletal surgery services rendered through the Emergency Department are not managed by Evolent and are exceptions to this authorization process.

Musculoskeletal surgery services rendered through the Emergency Department are not managed by Evolent. Evolent does not prior authorize or manage facility precertification for musculoskeletal surgery services delivered in the ED setting. Payment and authorization responsibilities for ED-rendered musculoskeletal surgical care are therefore handled outside of Evolent’s authorization process; providers should verify plan-specific ED workflows and payer requirements before submitting requests.

This policy does not list any explicit not medically necessary conditions or procedures. The document states no specific exclusions for medical necessity beyond the operational exclusion that ED-rendered musculoskeletal surgery services are not managed by Evolent.

CPT and Add-on Code Guidance

Lumbar microdiscectomy and decompression CPTsCPTCovered

63030	Lumbar Microdiscectomy (primary CPT listed)
62380	Microdiscectomy allowable billed grouping
63035	Add-on/in combination code for microdiscectomy
63005	Lumbar decompression primary CPT
63012	Lumbar decompression primary CPT
63017	Lumbar decompression primary CPT
63042	Lumbar decompression primary CPT
63044	Lumbar decompression add-on
63047	Lumbar decompression add-on
63048	Lumbar decompression add-on

1–10 of 12

1/2

Lumbar fusion and instrumentation CPTsCPTCovered

22612	Lumbar fusion single level (listed in document)
22630	Lumbar fusion related CPT
22633	Lumbar fusion related CPT
63052	Fusion/decompression related add-on
63053	Fusion/decompression related add-on
22840	Instrumentation add-on
22841	Instrumentation add-on
22842	Instrumentation add-on
22845	Instrumentation add-on
22853	Instrumentation add-on

1–10 of 12

1/2

Lumbar fusion multiple levels CPTsCPTCovered

22614	Lumbar fusion multiple levels (primary CPT)
22534	Lumbar related CPT listed in allowable billed groupings
22585	Lumbar related CPT listed in allowable billed groupings
22632	Lumbar related CPT listed in allowable billed groupings
22634	Lumbar related CPT listed in allowable billed groupings

Cervical surgery CPTs (decompression, fusion, artificial disc)CPTCovered

63075	Cervical anterior decompression (without fusion) primary CPT
63076	Cervical decompression add-on
22551	Anterior cervical decompression with fusion single level primary CPT
22552	Anterior cervical decompression with fusion multiple levels primary CPT
22864	Removal of artificial disc
63045	Cervical posterior decompression (without fusion) primary CPT
63001	Cervical decompression related CPT
63015	Cervical decompression related CPT
63020	Cervical decompression related CPT
63035	Add-on used in cervical decompression group

1–10 of 30

1/3

Add-on code policy noteModifier

+ (add-on modifier)

Add-on codes do not require separate authorization and are to be used in conjunction with approved primary code; multiple-level add-ons require authorization

inv-09: Authorization exception — Multiple level add-on codes require authorization

ExceptionMultiple-level add-on codes require prior authorization

ContextAdd-on codes billed with an approved primary code generally do not require separate authorization

Implication for billingWhen multiple-level add-on codes are submitted, include a separate authorization request specifying the multilevel procedure

Plan limitation notePayment remains contingent on patient eligibility and plan limitations at time of service

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for the primary spine surgical procedure. If the main surgical procedure is approved via authorization, CPT add‑on codes and ancillary codes billed in conjunction with the approved primary procedure are generally included and do not require a separate authorization.

Add‑on codes (+) are included with the approved primary CPT code and do not require separate authorization.
Exception: multiple‑level add‑on codes require authorization when used for multiple‑level procedures.

Note

Provider Action — Submit Primary Authorization

Providers should submit a single prior authorization request for the primary spine surgery. When authorization is granted for the primary procedure, commonly associated CPT codes that are part of that procedure are assumed to be included and do not need separate precertification.

Submit authorization for the primary CPT code representing the requested spine procedure.
Do not submit separate authorizations for ancillary or commonly bundled CPTs that are part of the approved primary procedure.

Billing Rule

Primary Authorization Covers Associated CPTs

Primary authorization covers associated CPTs: when the main surgical procedure is approved via authorization, multiple associated CPT codes that are part of that procedure are assumed included. Ancillary procedure codes listed by the plan do not require prior authorization if billed with an approved primary procedure.

Ancillary procedures/codes included with an approved primary surgery do not require separate prior authorization.
This is not an all‑inclusive list of ancillary codes; use clinical judgment and contact the plan if uncertain.

Denial Risk

Coverage Contingent on Eligibility

Coverage and payment are contingent on the patient’s eligibility and plan limitations at the time of service. Musculoskeletal surgery services rendered through the Emergency Department are not managed by Evolent; Evolent does not prior authorize or manage facility precertification for musculoskeletal surgery services.

Payment contingent on member eligibility and plan limits at time of service.
ED‑rendered musculoskeletal surgery services are excluded from Evolent management.
Evolent does not manage facility precertification for these services.

Background

This document provides an overview of common spine surgical categories and their primary CPT codes, grouping related decompression, discectomy, fusion, instrumentation, and ancillary codes that are typically billed with an authorized primary procedure. Examples include lumbar microdiscectomy and decompression codes (e.g., 63030 and related decompression/add-on codes), lumbar fusion and instrumentation codes for single-level procedures (e.g., 22612, instrumentation codes such as 22840–22845, and bone graft/aspiration codes like 20930–20939), multicompartment lumbar fusion codes for multiple levels (e.g., 22614 and related level-based CPTs), and a range of cervical decompression, fusion, and artificial disc codes (including single- and multilevel fusion CPTs, decompression CPTs, and artificial disc codes such as 22856/22858 and associated add-on codes). Add-on codes marked with a plus sign are generally included with an approved primary procedure and do not require separate authorization, except that multiple-level add-on codes do require authorization.