Total Facet Arthroplasty
Customize your policy alerts
Sign up for Geisinger Health Plan Policy MP235 alerts
Get alerted when Policy MP235 changes without checking for updates manually.
Monitor payer policy activity
Policy governing coverage and prior authorization requirements for total facet (posterior vertebral joint) arthroplasty procedures for Geisinger Health Plan members across applicable lines of business.
No material clinical or coverage changes in this revision.
Coverage Criteria
Coverage contingent on prior authorization and benefit documents
Coverage is contingent on meeting applicable prior authorization requirements and the member's line-of-business benefit rules.
For applicable Commercial HMO/PPO, Medicare Advantage, GHP Family Medicaid and CHIP products, prior authorization through Cohere is required; line-of-business specific benefit documents and, for Medicare, applicable LCDs and NCDs supersede this policy.
Coverage for experimental, investigational or unproven treatments, services and procedures is specifically excluded under the member's certificate with Geisinger Health Plan. Unproven services performed outside an approved clinical trial are also specifically excluded. This policy does not expand coverage to items or services that are expressly excluded by the member's benefit document; see policy MP015 Experimental, Investigational or Unproven Services for additional details.
The inclusion of a procedure or device code in this policy is for informational purposes only and does not constitute or imply coverage nor guarantee provider reimbursement. Coverage determinations are made according to the member's specific benefit plan document and applicable laws; for Medicare members, only CPT/HCPCS codes covered by Medicare rules may apply. Providers should consult the member contract and applicable CMS guidance when assessing coverage eligibility.
Coding
| 0202T | Posterior vertebral joint(s) arthroplasty (eg, facet joint[s] replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine |
Provider Actions
Obtain prior authorization through Cohere
Prior authorization is required through Cohere for applicable Commercial HMO/PPO, Medicare Advantage, GHP Family Medicaid and CHIP products; follow Cohere's clinical criteria and decision‑support tools when submitting requests.
- Applies to specified Commercial HMO/PPO, Medicare Advantage, GHP Family Medicaid and CHIP products.
- See Cohere and payer website for clinical criteria and required documentation.
Provider impact: Cohere routing and benefit overrides
Geisinger requires prior authorization routed through Cohere for the listed lines of business; eligibility and contract‑specific benefits, limitations, or exclusions in the member's benefit document will supersede this policy.
- Refer to member's line‑of‑business benefit document for final coverage determination.
- Cohere uses proprietary clinical criteria and utilization management decision‑support tools for determinations.
Include CPT 0202T and follow Cohere prior authorization process
Include CPT code 0202T on prior authorization requests and follow Cohere's prior authorization process and clinical criteria as directed on the payer/Cohere website.
- Procedure code to include on requests: 0202T (Posterior vertebral joint(s) arthroplasty).
- Follow Cohere submission instructions and required supporting clinical documentation available via the payer/Cohere site.
Denial risk if Cohere prior authorization not obtained
Lack of prior authorization through Cohere for the applicable products may result in non‑coverage or denial of the service; coverage is ultimately determined by the member's benefit plan.
- Inclusion of a procedure code does not guarantee coverage or reimbursement.
- Member specific benefit documents and applicable laws determine final coverage; Medicare LCDs/NCDs may supersede this policy.
Background
Total facet arthroplasty refers to the implantation of a spinal prosthesis to restore posterior element structure and function as an adjunct to neural decompression. It is proposed as an alternative to posterior spinal fusion for patients with conditions such as facet arthrosis, spinal stenosis, or spondylolisthesis and typically involves procedures such as facetectomy, laminectomy, foraminotomy, and may include vertebral column fixation or injection of bone cement when performed.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.