CurrentEmblemHealthPolicy N/A

Spine Surgery and Pain Management Therapies Prior Authorization Program

Defines EmblemHealth's utilization management program requiring providers to obtain prior approval from OrthoNet for select spine surgery and interventional pain management procedures across inpatient and outpatient settings for applicable network members.

Policy Summary

PayerEmblemHealth

PolicySpine Surgery and Pain Management Therapies Prior Authorization Program

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 16, 2015

Next Review DateN/A

Key ActionProviders must obtain prior approval from OrthoNet before performing listed spine surgery and interventional pain management procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-2 daysreview turnaround

90 daysprior approval valid

1-844-730-8503OrthoNet phone

1-844-296-4440OrthoNet fax

Nov 16, 2015effective

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Coverage & Applicability

Prior authorization

Prior approval required for listed procedures when performed in the specified settings

Prior authorization requirement: Prior approval obtained from OrthoNet for procedures on the program code list

Applies to POS 11, 21, 22, 24 and to specified included networks

This program applies only to members enrolled in specified EmblemHealth networks. Included networks and any exceptions are listed in the program materials and provider guidance (see program chapter and toolkit). Providers must verify member network eligibility before requesting OrthoNet prior approval.

Claims for procedures that require OrthoNet prior approval must include the appropriate approval on the claim; claims submitted without the required prior approval will be denied. Prior approval must be obtained from OrthoNet before treatment begins for procedures on or after November 16, 2015.

Intrathecal pain pump procedures are eligible for coverage only when billed in conjunction with qualifying diagnosis codes. The policy requires the pump procedure to be linked to specified diagnoses (examples include ICD-9 ranges 721.*–724. and 338.1, 338.2, 338.4, and the listed ICD-10 spine codes); pumps billed without an associated qualifying diagnosis are not eligible for coverage.

OrthoNet performs utilization management reviews to determine whether the proposed service meets the plan's definition of medical necessity under the member's benefit. Prior approval decisions are rendered by OrthoNet clinical reviewers as part of that medical necessity determination.

Code Lists & Effective Dates

Prior approval effective datemixed

Effective Date

Procedures on or after November 16, 2015 require OrthoNet approval

Spinal Fusion — CPT/HCPCS (partial list)CPTCovered

0195T
0196T
0309T
22532
22533
22534
22548
22551
22552
22585

1–10 of 36

1/4

Decompression Surgery — CPT/HCPCS (partial list)CPTCovered

63001
63003
63005
63011
63012
63015
63016
63017
63020
63030

1–10 of 19

1/2

Kyphoplasty / Vertebroplasty / Epidural Injections — CPT/HCPCSCPTCovered

S2360	Kyphoplasty
S2361	Vertebroplasty
22310	Vertebroplasty
22315	Vertebroplasty
22510	Vertebroplasty
22512	Vertebroplasty
22513	Vertebroplasty
22514	Vertebroplasty
22515	Vertebroplasty
62310	Epidural injection

1–10 of 15

1/2

Epidural and Facet Injections — CPT/HCPCSCPTCovered

64490	Facet injection
64491	Facet injection
64492	Facet injection
64493	Facet injection
64494	Facet injection
64495	Facet injection

Spinal Cord Stimulator — CPT/HCPCSCPTCovered

0282T
0283T
0284T
63661
63662
63663
63664
63685
63688

Pain Pump — CPT/HCPCSCPTCovered

62318
62355
62365
62319
62360
62350
62361
62351
62362

Pain Pump — ICD-10 Procedure codes (includes required entries)ICD-10

OTHDO3Z
OTHD33Z
OTHD43Z
OTHD73Z
OFHB33Z
OFHB43Z
OFHB73Z

Spine surgery — ICD-10-PCS procedure codes (neutral, partial list)ICD-10

OTHDO3Z
OTHD33Z
OTHD43Z
OTHD73Z
OFHB33Z
OFHD33Z
OFHD73Z

Associated ICD-10 Diagnosis codes for pain pump and spine conditions (required entries)ICD-10

M54.41
M54.42
M51.14
M51.15
M51.16
M51.17
M54.14
M54.15
M54.16
M54.17

1–10 of 29

1/3

Other CPT/HCPCS codes — always require prior approvalCPTCovered

22818
22819
22855
22862
22864
22865

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior approval is required from OrthoNet for the spine surgery and interventional pain management CPT/HCPCS codes listed in the program code set. Providers must obtain prior approval for any procedure on or after November 16, 2015 that is included in the code list; claims for procedures that require OrthoNet prior approval will be denied if the appropriate approval is not obtained before treatment.

Applies to inpatient (POS 21), outpatient hospital (POS 22), ambulatory surgery center (POS 24) and office (POS 11) settings
Listed CPT/HCPCS codes always require prior approval — failure to obtain prior approval may result in claim denial

Documentation Required

Required Documentation for Prior Authorization

Include complete provider and treatment location identification, member information, and request details on the OrthoNet Fax Request form to avoid delays. OrthoNet requires sufficient patient-specific clinical information to render a decision.

Provider/facility name and corresponding NPI or Tax ID
Treatment location address, city, state, ZIP
Member name, date of birth, EmblemHealth member ID
Diagnosis code(s) and spinal level
Requested procedure and anticipated date of service
Service setting and contact telephone/fax numbers

Note

Conservative Treatment Review

OrthoNet will review documentation of prior conservative treatments as part of the medical necessity review. Be prepared to provide the patient’s treatment history, including prior nonsurgical management, prior procedures, and any prior surgeries.

Relevant patient history including conservative treatments and prior surgeries
Copies of significant imaging reports (MRI, CT, X‑rays) and relevant electrodiagnostic studies
Proposed treatment plan and description of the planned surgery, including implants when applicable

Program Background

The program centralizes utilization management for spine surgery and interventional pain therapies through OrthoNet. Providers must obtain prior approval for the defined procedure code list and submit relevant clinical information; reviews are completed by licensed clinicians with specialty training supported by board‑certified physicians to confirm that the proposed service meets medical necessity under the member's benefit plan.

Key Definitions

Medical necessity

DefinitionMedical necessity determination: the program will determine whether the proposed service meets the definition of medical necessity under the member's benefit plan

Responsible entityOrthoNet performs utilization management reviews on behalf of EmblemHealth

Applies toSpine surgery and interventional pain management procedures defined by the program code list

Clinical reviewer

Reviewer qualificationsReviews are performed by a licensed health care professional with additional specialty training

Physician supportClinical reviews are supported by board‑certified MDs and DOs

Scope of reviewPrior approval requests are reviewed for medical necessity by these trained clinicians

Pain Pump coverage condition

Coverage conditionPain pumps are eligible for coverage only when billed with specified spine‑related diagnosis codes (policy lists both ICD‑9 ranges such as 721.*‑724., 338.1, 338.2, 338.4 and numerous ICD‑10 spine codes)

Required coding linkageClaims for pain pump procedures must include an associated qualifying diagnosis code from the policy's ICD‑9 or ICD‑10 lists

Non‑coverage riskPain pumps billed without one of the specified diagnosis codes are not eligible for coverage under this program

Prior Authorization Review & Imaging