Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesPain ManagementOrthoNet Pain and Spine Coverage Update | OpenPaye…
    Ask Trek AI about this page
    CurrentorthonetPolicy N/A

    Clinical Criteria used 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 sources OrthoNet uses to guide utilization management decisions for pain and spine services for members and providers.

    Policy Summary
    Payerorthonet
    PolicyClinical Criteria used for Pain and Spine Utilization Management
    Policy CodePolicy N/A
    Change TypeRoutine review — no material changes
    Effective DateJan 12, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization requests using OrthoNet clinical criteria with referenced Emblem, MCG 29th Edition, and applicable NCD/LCD documentation.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    MCG 29thclinical guideline edition referenced
    Multiple LCDs/NCDsMedicare coverage resources listed
    Emblem referencedexternal payer policies used

    Coverage determination and scope

    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.

    General coverage determination

    OrthoNet covers or authorizes pain and spine services when determinations meet the cited clinical criteria and referenced external policies/guidelines.

    Reference hierarchy: When EmblemHealth medical policies exist for a service, OrthoNet will use those policies; if no Emblem policy is available, OrthoNet will use MCG guidance.

    Supported by chunks 6

    Use of Medicare coverage determinations: OrthoNet references applicable National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) when making determinations for specific procedures.

    Examples include NCDs/LCDs listed in chunk 1 (electrical nerve stimulators, infusion pumps, epidural steroid injections, facet interventions, PVA, sacroiliac procedures, cervical fusion)

    Application to utilization management: Utilization management decisions for pain and spine services are determined by the type of service requested and the member's health plan and must meet the clinical criteria from the applicable Emblem policy, MCG guideline, or NCD/LCD.

    Supported by chunks 0 and 6

    This document does not list any standalone procedure-level exclusions. Coverage determinations rely on the referenced external resources: when an EmblemHealth medical policy exists for a service, OrthoNet will apply that policy; if no Emblem policy is available, OrthoNet will apply the applicable MCG guidance and, where relevant, NCD/LCD references to identify any procedure-specific exclusions.

    The policy does not enumerate specific procedures as categorically not medically necessary. Instead, determinations that a requested service is not medically necessary are made by applying OrthoNet’s clinical criteria and the referenced coverage resources (EmblemHealth policies, MCG 29th Edition guidelines, and applicable NCD/LCDs) to the member’s diagnosis and the service requested.

    Referenced coding and guideline identifiers

    Referenced NCDs and LCDsmixed
    160.7National Coverage Determination (NCD) Electrical Nerve Stimulators
    280.14National Coverage Determination (NCD) Infusion Pumps
    L39036LCD Epidural Steroid Injections for Pain Management
    L35936LCD Facet Joint Interventions for Pain Management
    L33569LCD Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)
    L39455LCD Sacroiliac Joint Injections and Procedures
    L39770LCD Cervical Fusion
    MCG guideline identifiers citedmixed
    A-0420MCG 29th Edition Intrathecal Pump Implantation ACG
    S-320MCG 29th Edition Cervical Fusion, Anterior ORG
    S-330MCG 29th Edition Cervical Fusion, Posterior ORG
    SG-NSMCG 29th Edition Neurosurgery or Procedure GRG
    SG-MSMCG 29th Edition Musculoskeletal Surgery or Procedure GRG
    S-530MCG 29th Edition Removal of Posterior Spinal Instrumentation ORG
    A-0227MCG 29th Edition Disk Arthroplasty, Cervical ACG
    S-340MCG 29th Edition Cervical Laminectomy ORG
    S-830MCG 29th Edition Lumbar Laminectomy ORG
    S-810MCG 29th Edition Lumbar Diskectomy, Foraminotomy, or Laminotomy ORG
    1–10 of 13
    1/2

    Prior authorization and provider guidance

    Prior Authorization

    Prior authorization requirement

    Prior authorization decisions for pain and spine services are made using OrthoNet clinical criteria. When an Emblem policy exists for the requested service, OrthoNet will apply that policy; if no Emblem policy is available, OrthoNet will use MCG guidance (including the MCG 29th Edition) and applicable NCD/LCD references to make the authorization determination.

    • Use Emblem policies preferentially; if none exist, use MCG guidance (MCG 29th Edition listed).
    • MCG guideline identifiers (examples) include A-0420, S-320, S-330, SG-NS, SG-MS, S-530, A-0227, S-340, S-830, S-810, A-0226, P-1056, S-1056.
    Note

    Provide service-specific clinical justification

    Clinical determinations for utilization management are based on the type of service requested and the member's health plan; providers must submit requests with the clinical information needed to show the requested service meets the cited clinical criteria.

    • Follow Emblem policy when available, otherwise follow the referenced MCG guidance.
    • Include service type, diagnosis, and documentation that demonstrates conformance with the cited guideline for the requested procedure.
    Denial Risk

    Reference cited clinical criteria in appeal/response

    Partial approval and denial letters will cite the clinical criteria used and direct providers to the appropriate website link for the cited guideline; when responding, providers should reference the specific MCG or Emblem policy named in the communication.

    • The partial approval/denial letter will identify which clinical criteria (Emblem or MCG) were applied and include the website link to the cited resource.
    • Select the website link referenced in the letter to find the exact clinical criteria used in the determination.
    Denial Risk

    Clinical determinations guide approvals and denials

    Utilization management determinations rely on the combination of the requested service type and the member's health plan; requests that do not meet the cited Emblem, MCG (29th Edition), or applicable NCD/LCD criteria may be denied.

    • MCG 29th Edition (effective 1/12/26) is among the referenced guidelines used when Emblem policies are not available.
    • Providers should ensure requests align with Emblem policy, MCG guidance, or applicable NCD/LCDs to avoid denial.

    Policy background and purpose

    OrthoNet’s clinical criteria are used to guide management and treatment decisions for members based on the presenting diagnosis and the specific service requested. When EmblemHealth medical policies exist, OrthoNet uses those policies preferentially; if no Emblem policy is available, OrthoNet applies MCG guidance (for example, MCG 29th Edition) and references applicable NCDs/LCDs to reach utilization management determinations.

    Key definitions

    inv-11: Clinical criteria definition
    DefinitionA medical guideline document used to guide clinical decisions for management and treatment of a member related to the specific diagnosis presented.
    PurposeGuides clinical decisions for management and treatment of members for specific diagnoses and requested pain/spine services.
    Scope of useOrthoNet uses these clinical criteria to make utilization management and prior authorization decisions based on the type of service requested and the member's health plan.
    Reference hierarchyWhen EmblemHealth medical policies exist for a service, OrthoNet will use those policies; if no Emblem policy is available, OrthoNet will use MCG guidance.
    Examples of referenced sourcesMCG guidelines, Emblem policies, and applicable Medicare NCDs/LCDs are used to form the clinical criteria.

    Conservative care and preauthorization prerequisites

    Procedure frequency and interval limits

    inv-13: Frequency limits
    General ruleProcedure-specific frequency limits are determined by the cited LCDs/NCDs or MCG guidelines.
    Medicare sourcesNational Coverage Determinations (NCD) and Local Coverage Determinations (LCD) cited include NCD Electrical Nerve Stimulators (160.7), NCD Infusion Pumps (280.14), and multiple LCDs (L39036, L35936, L33569, L39455, L39770).
    MCG sourcesMCG 29th Edition guidelines cited (e.g., A-0420, S-320, S-330, SG-NS, SG-MS, S-530, A-0227, S-340, S-830, S-810, A-0226, P-1056, S-1056) provide frequency and utilization guidance when Emblem policies are not available.
    How to applyProviders and reviewers should follow the frequency limits and intervals specified in the applicable LCD/NCD or the corresponding MCG guideline for the requested procedure.

    Imaging and documentation requirements

    Documentation Required

    Follow cited MCG/Emblem links for imaging

    For imaging and other documentation requirements cited in approval/denial letters, providers should follow the specific MCG or Emblem policy links referenced in the communication.

    • Select the appropriate website link listed in the letter (MCG Client Resources or Emblem policy) to view imaging and documentation details.
    • MCG 29th Edition references (effective 1/12/26) are used when indicated in the communication.
    Policy Summary
    Payerorthonet
    PolicyClinical Criteria used for Pain and Spine Utilization Management
    Policy CodePolicy N/A
    Change TypeRoutine review — no material changes
    Effective DateJan 12, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization requests using OrthoNet clinical criteria with referenced Emblem, MCG 29th Edition, and applicable NCD/LCD documentation.
    SourceLink
    On This Page
    Coverage determination and scopeReferenced coding and guideline identifiersPrior authorization and provider guidancePolicy background and purposeKey definitionsConservative care and preauthorization prerequisitesProcedure frequency and interval limitsImaging and documentation requirements