CurrentorthonetPolicy N/A

Clinical Criteria for Pain and Spine Utilization Management

Customize your policy alerts

Sign up for all orthonet policy alerts

Know when orthonet releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines the clinical criteria and reference guidelines OrthoNet uses to make utilization management decisions for pain and spine services across member health plans; affects providers requesting pain and spine procedures for OrthoNet members.

Policy Summary

Payerorthonet

PolicyClinical Criteria for Pain and Spine Utilization Management

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionProviders must submit clinical information sufficient for OrthoNet to apply the referenced clinical criteria and guideline sources when requesting pain and spine services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MCG 29clinical guideline edition in use

Multiple LCD/NCDexternal coverage determinations referenced

OrthoNet care guidelinesinternal topic-specific guidance available

Coverage & Medical Necessity Criteria

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.

CurrentorthonetPolicy N/A

Clinical Criteria for Pain and Spine Utilization Management

Customize your policy alerts

Sign up for all orthonet policy alerts

Know when orthonet releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

Payerorthonet

PolicyClinical Criteria for Pain and Spine Utilization Management

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionProviders must submit clinical information sufficient for OrthoNet to apply the referenced clinical criteria and guideline sources when requesting pain and spine services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MCG 29clinical guideline edition in use

Multiple LCD/NCDexternal coverage determinations referenced

OrthoNet care guidelinesinternal topic-specific guidance available

Coverage & Medical Necessity Criteria

General coverage decision logic

Coverage and medical necessity determinations are made by applying ALL relevant referenced sources to the requested service.

Referenced sources: Decisions require applying applicable NCDs/LCDs, MCG Health guidance (29th Edition where applicable), and OrthoNet Care Guidelines to the member's clinical presentation and requested service.

Providers must supply clinical information for these assessments; utilization determinations depend on the service requested and the member's health plan.

No additional procedural exclusions are listed within this OrthoNet document. Coverage and medical necessity determinations are made by applying ALL applicable referenced sources (NCDs/LCDs, MCG Health guidance, and OrthoNet care guidelines) to the requested service and the member's clinical presentation. Specific exclusions that appear in a referenced NCD, LCD, or MCG guideline apply as specified in those source documents and will govern the determination.

Items that do not meet the referenced clinical criteria from the applicable NCDs/LCDs, MCG guidance, or OrthoNet care guidelines are not covered and may be determined not medically necessary through OrthoNet's utilization review process. Procedural details, including indications, conservative care prerequisites, imaging requirements, and frequency limits, are governed by the specific referenced source(s) cited for each procedure and must be followed when submitting requests for review.

Referenced Codes and Coding References

Referenced NCDs/LCDsmixed

160.7	NCD Electrical Nerve Stimulators
280.14	NCD Infusion Pumps
L39036	LCD Epidural Steroid Injections for Pain Management
L35936	LCD Facet Joint Interventions for Pain Management
L33569	LCD Percutaneous Vertebral Augmentation (PVA) for Osteoporotic VCF
L39770	LCD Cervical Fusion
L39455	LCD Sacroiliac Joint Injections and Procedures
L34328	LCD Peripheral Nerve Stimulation (Noridian) Revision 10
L39543	LCD Sacral Nerve Stimulation for Urinary and Fecal Incontinence (Palmetto)

Referenced MCG guidance codes/topicsmixed

A-0420	MCG Intrathecal Pump Implantation
S-320	MCG Cervical Fusion, Anterior
S-820	MCG Lumbar Fusion, Posterior
S-330	MCG Cervical Fusion, Posterior
SG-NS	MCG Neurosurgery or Procedure GRG
SG-MS	MCG Musculoskeletal Surgery or Procedure GRG
S-530	MCG Removal of Posterior Spinal Instrumentation
A-0227	MCG Disk Arthroplasty, Cervical
A-0494	MCG Spinal Distraction Devices
S-340	MCG Cervical Laminectomy

1–10 of 17

1/2

Provider Requirements and Prior Authorization

Prior Authorization

Prior authorization follows NCD/LCD, MCG 29th Edition, and OrthoNet guidelines

Prior authorization decisions for pain and spine services are determined using OrthoNet’s clinical criteria and the referenced guideline sources. OrthoNet applies applicable NCDs/LCDs, MCG Health guidance (29th Edition effective 1/1/26), and OrthoNet care guidelines when making utilization management determinations.

Note

Utilization determinations vary by service and health plan

OrthoNet’s utilization determinations depend on the type of service requested and the member’s health plan; providers should expect decisions to follow the referenced external and internal criteria collections rather than a single flat rule set.

Documentation Required

Submit clinical information to support application of referenced criteria

Providers must submit sufficient clinical information to allow OrthoNet to apply the referenced NCDs/LCDs, MCG 29th Edition guidance, and OrthoNet care guidelines to the requested pain or spine service.

Denial Risk

Risk of denial if referenced clinical criteria are not met

Requests that do not meet the applicable referenced clinical criteria (NCDs/LCDs, MCG guidance, or OrthoNet care guidelines) may be denied; utilization management determinations are made based on the requested service and the patient’s health plan.

Conservative Care Requirements

Conservative treatment requirements

Follow conservative care requirements as specified in the applicable MCG guideline or OrthoNet care guideline for the procedure requested.

Conservative care requirement: Providers must follow the conservative therapy and prerequisite care requirements defined in the applicable MCG Health guideline (29th Edition where specified) or the corresponding OrthoNet care guideline for the specific procedure (for example: epidural steroid injection, facet block, sacroiliac joint injection, nerve stimulation procedures).

Specific conservative treatment elements, duration, and stepwise therapies are those detailed in the referenced MCG guidance or OrthoNet care guideline for each procedure; consult the cited guideline for procedure-level requirements.

Imaging and Diagnostic Requirements

Note

Follow LCD/NCD and MCG guidelines for imaging requirements

Imaging requirements for a requested procedure are determined by the applicable LCD/NCD and the MCG Health guidelines (29th Edition where applicable); consult the referenced coverage determinations and MCG topic guideline for procedure-specific imaging rules.

Frequency Limits and Utilization Controls

Frequency limits and sources

Source of frequency limitsFrequency limits are not specified in this document; limits are defined by the referenced LCDs, NCDs, or MCG Health guidelines.

MCG guidance effective dateMCG 29th Edition effective 1/1/26 applies where referenced.

LCD/NCD responsibilityWhen an LCD or NCD specifies a frequency limit for a procedure, that limit governs OrthoNet determinations for that procedure.

Provider actionProviders should consult the specific referenced LCD/NCD or MCG guideline for procedure-specific frequency and interval rules when requesting services.

Documentation implicationPrior authorization and utilization decisions will reference the frequency constraints contained in the cited external guidance.

Non-Covered Items and Exclusions

This document does not enumerate procedural indications that are explicitly not covered. Instead, coverage exclusions and not‑covered determinations are controlled by the referenced NCDs/LCDs and MCG guidance; any not covered items identified in those sources will apply to OrthoNet's determinations.

Definitions and Guideline Terms

Clinical criteria / medical guideline — definition and use

DefinitionClinical criteria / medical guideline: a document for guiding clinical decisions for the management and treatment of a member related to the specific diagnosis presented; used by OrthoNet to make utilization management determinations.

Referenced sourcesOrthoNet applies applicable NCDs/LCDs (e.g., NCD 160.7, 280.14; LCDs L39036, L35936, L33569, etc.), MCG Health guidelines (29th Edition where applicable), and OrthoNet care guidelines to guide decisions.

PurposeThese clinical criteria guide prior authorization and medical necessity determinations for pain and spine procedures.

Provider responsibilityProviders must supply sufficient clinical information so OrthoNet can apply the referenced clinical criteria and guideline sources.

Examples of OrthoNet care guidelinesOrthoNet care guidelines include Epidural Spinal Cord Stimulator, Epidural Steroid Injection, Facet Block Injection, Sacroiliac Joint Injection, and others.

Background and Guideline Sources

OrthoNet uses established national and local coverage determinations (NCDs/LCDs), MCG Health guidelines, and OrthoNet-specific care guidelines to guide utilization management for pain and spine procedures. The policy references multiple CMS NCDs/LCDs for procedures such as electrical nerve stimulators, infusion pumps, epidural steroid injections, facet interventions, vertebral augmentation, fusion, sacroiliac procedures, and peripheral nerve stimulation, and it uses MCG Health guidance (29th Edition, effective 1/1/26) for procedure-specific clinical criteria. Providers must follow the applicable referenced source for procedure indications, conservative care requirements, imaging, and frequency limits when requesting authorization.

Policy Summary

Payerorthonet

PolicyClinical Criteria for Pain and Spine Utilization Management

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionProviders must submit clinical information sufficient for OrthoNet to apply the referenced clinical criteria and guideline sources when requesting pain and spine services.

SourceLink

On This Page