Prior Authorization Required

Prior authorization is required per the member's plan procedures before scheduling disc decompression surgeries. Coverage is contingent upon meeting the clinical criteria in this policy and any applicable plan administrative requirements.

• Prior authorization required for listed procedure codes supporting coverage.
• Coverage decisions subject to plan administrative policies and prior authorization process.

Denial Risk from Coverage Terms

Services that are not consistent with the coverage terms of this policy may be denied. Claims for procedures, devices, or codes that do not meet the medical necessity criteria or are listed as not supporting coverage are at risk for denial.

• Claims using interspinous/interlaminar devices (e.g., 22867-22870, C1821) or percutaneous decompression codes listed as not supporting coverage (e.g., 62330-62331, S2348) may be denied.
• Services not documented to meet policy criteria or excluded by plan terms may be denied.

Required Clinical Documentation for Surgical Coverage

When requesting authorization for open discectomy or microdiscectomy, include complete clinical documentation to substantiate medical necessity. Documentation must demonstrate diagnosis, imaging confirmation, neurological findings, and prior conservative therapy.

• Diagnosis of herniated lumbar disc and nerve root compression confirmed by imaging (e.g., MRI/CT).
• Detailed neurologic exam notes documenting motor or sensory deficits (MRC motor scale scores when applicable).
• Progress notes showing duration and response to conservative therapy and any inability to tolerate therapy.
• If applicable, documentation of worsening weakness or progressive neurologic deficit.

Documentation and Contractual Compliance

Providers must comply with contractual documentation and coverage requirements. This policy is proprietary to the Health Plan; unauthorized use is prohibited. When state Medicaid or Medicare NCDs/LCDs conflict with this policy, the applicable program rules take precedence.

• Submit operative reports, imaging reports, and relevant office visit notes with prior authorization requests and claims.
• For Medicaid members, follow state Medicaid coverage provisions where they differ from this policy.
• For Medicare members, review applicable NCDs, LCDs, and Coverage Articles prior to applying policy criteria.

Conservative Therapy Prerequisites

Prior to considering surgical intervention, members must have adequate trials of conservative therapy as defined in this policy. Failure to document required conservative management may render a request not medically necessary.

• ≥ four weeks of physical therapy or prescribed home exercise program (or documentation of inability to tolerate).
• ≥ four weeks of activity modification.
• Either ≥ three weeks of NSAID or acetaminophen unless contraindicated/not tolerated, or an epidural steroid injection as appropriate.