Submit one PA that lists all planned/possible procedures

Include all planned or potentially necessary diagnostic or therapeutic procedures for the same surgery in a single prior authorization request; each procedure requiring prior authorization will be reviewed individually for medical necessity.

• If documentation does not support all requested services, a partial approval may be issued.
• If additional procedures not fully approved are performed intraoperatively, submit clinical documentation with the claim showing intraoperative findings to support medical necessity; if denied, request reconsideration through the standard process.

Obtain prior authorization for listed and unlisted potentially covered procedures

Certain listed procedures require prior review/authorization; to avoid post-service denial, prior authorization is recommended for unlisted codes submitted for potentially covered services addressed in this policy.

• Some procedures may also require review under the Outpatient Surgical Site of Service policy (see revision notes).
• Inclusion or omission of a code in the policy does not guarantee reimbursement; check member benefits and provider contracts.

Provide complete clinical documentation with the PA request

Follow the documentation checklist when submitting a PA: include the indication for surgery, clinical documentation of conservative care and its response, and evaluation of functional impairments or disabilities.

• Document outcomes of prior procedural interventions, medication use, and physical therapy notes.
• Include imaging completed within the past 12 months and documented x‑ray interpretation; if advanced imaging is required, include the radiologist's report.
• Provide any criteria-specific lab values or reports.

Document and submit intraoperative findings for unapproved additional procedures

If intraoperative findings necessitate additional procedures not included or fully approved in the PA, submit supporting clinical documentation with the claim showing those findings; you may request reconsideration if the claim is denied for not meeting medical necessity.

• Partial approvals may be issued when documentation does not support all requested services (see risk callout).

Required clinical documentation checklist

Submit the following required clinical documentation to determine medical necessity: indication for surgery; extent and response to conservative care (including outcomes of prior procedures); evaluation of functional impairments; imaging within 12 months with x‑ray interpretation and radiologist reports for advanced imaging; and any criteria‑specific labs or reports.

• Conservative care documentation should include physical therapy notes, activity modification, and analgesic use as applicable.
• If imaging interpretations conflict, the radiologist's report supersedes the surgeon's interpretation.

Unlisted codes are reviewed; recommend PA to avoid post‑service denial

All unlisted codes will be reviewed at the claim level for medical necessity, correct coding, and pricing; to avoid post‑service denial, prior authorization is recommended when an unlisted code is submitted for a potentially covered service.

• If an unlisted code is submitted for a non‑covered service addressed in this policy, it will be denied as not covered.

Risk of partial approval when documentation is insufficient

If documentation does not support all services requested in a single prior authorization, the plan may issue a partial approval; performing additional procedures not approved in the PA risks claim denial unless intraoperative findings are submitted for reconsideration.

• Providers should include all potentially necessary procedures in the initial PA to reduce the risk of partial approval.

Unlisted codes for non‑covered services will be denied

Unlisted codes submitted for services that this policy identifies as non‑covered will be denied as not covered.

• Review the policy's non‑covered sections before billing unlisted codes; obtain PA for any potentially covered service to avoid denial.