Spinal Conditions Management and Joint Surgery Program Prior Authorization Code Matrix Applies to the Following Tufts Health Plan Products

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Spinal Conditions Management and Joint Surgery Program Prior Authorization Code Matrix Applies to the following Tufts Health Plan products:

☒ Tufts Health Plan Commercial (including Tufts Health Freedom Plan)1 ☐ Tufts Medicare Preferred HMO (a Medicare Advantage product) ☐ Tufts Health Plan Senior Care Options (SCO) (a dual-eligible product)

Applies to the following Tufts Health Public Plans products:

☒ Tufts Health Direct (a Massachusetts Qualified Health Plan [QHP]; a commercial product) ☒ Tufts Health Together (a MassHealth MCO Plan and Accountable Care Partnership Plans) ☒ Tufts Health RITogether (a Rhode Island Medicaid Plan) ☐ Tufts Health Unify (OneCare Plan; a dual-eligible product)

Note: Audit and disclaimer information is located at the end of this document. The matrix below contains all of the CPT codes for which NIA will authorize on behalf of Tufts Health Plan. The CPT codes for interventional pain management (IPM), spinal surgery and joint surgery services are subject to prior authorization by NIA. Certain procedures, items and/or services may require referral and/or prior authorization. While you may not be the provider responsible for obtaining prior authorization, as a condition of payment you must confirm that prior authorization has been obtained. Tufts Health Plan does not compensate add-on codes (prefixed with +) if the primary procedure code has not been submitted for the same date of service. Add-on codes pertain to services performed in conjunction with a primary procedure and should never be reported as a stand-alone service. Refer to the AMA CPT manual for additional information. INTERVENTIONAL PAIN MANAGEMENT: OUTPATIENT² If a procedure from the allowable billed groupings is billed, and a valid authorization number for the corresponding authorized CPT procedure code has been issued within the date of service validity period, the service is eligible for coverage, subject to the provisions of the member’s benefit plan document. Services for IPM rendered as part of emergency department (ED) services, observation services or in a hospital inpatient setting, are not subject to prior authorization. If the billed CPT code does not match a corresponding CPT code from the allowable billed groupings, the claim will deny and the member is not responsible.

Procedure Primary CPT Code Allowable Billed Groupings Cervical/thoracic interlaminar epidural 62321 62320, 62321, 64479, +64480 Cervical/thoracic transforaminal epidural 64479 62320, 62321, 64479, +64480 Lumbar/sacral interlaminar epidural 62323 62322, 62323, 64483, +64484 Lumbar/sacral transforaminal epidural 64483 62322, 62323, 64483, +64484 Cervical/thoracic facet joint block³ 64490 64490, + 64491, +64492

1 Commercial products include HMO, POS, PPO, USFHP, Tufts Health Freedom Plan, and CareLinkSM when Tufts Health Plan is the primary administrator. 2 Add-on codes do not require separate authorization and are to be used in conjunction with the approved primary code for the service rendered. 3 The following CPT codes for procedures performed with ultrasound guidance are not a covered service and are nonreimbursable: 0213T, +0214T, +0215T, 0216T, +0217T, +0218T

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Procedure Primary CPT Code Allowable Billed Groupings Lumbar/sacral facet joint block³ 64493 64493, +64494, +64495 Cervical/thoracic facet joint radiofrequency 64633 64633, +64634 neurolysis Lumbar/sacral facet joint radiofrequency 64635 64635, +64636 neurolysis

Note: Due to the repeat nature of IPM procedures, multiple authorizations may exist within the same validity period. LUMBAR AND CERVICAL SPINE SURGERY² If a procedure from the allowable billed groupings column is billed and a valid authorization number for the corresponding authorized CPT procedure code has been issued within the date of service validity period, the service is eligible for coverage, subject to the provisions of the member’s benefit plan document. Spinal surgery services rendered as part of ED services are not subject to prior authorization. For procedures performed in an inpatient setting, inpatient notification is required from Tufts Health Plan in addition to the appropriate authorization from NIA. Spinal deformity surgery does not require prior authorization. If the billed CPT code does not match a corresponding CPT code from the allowable billed groupings column, the claim will deny and the member cannot be held responsible. Note: Spine surgeries typically have more than one CPT associated with each case and often times a decompression is performed during the fusion surgery; in these instances, both will be billed.

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LUMBAR SPINE SURGERY These codes do not require prior authorization. If the main surgical procedure is Authorization is provided for the primary surgery requested. approved, these codes are There are multiple CPT codes that can be associated with each procedure. understood to be These are assumed to be part of the primary surgery request and when included in completed in combination, do not require a separate prior authorization. conjunction and do not require prior authorization. Note: This is not an all-inclusive list of every ancillary code Primary Additional Primary Primary Surgery Ancillary Other Covered Surgery CPT Allowable Procedures / Procedure Procedures / Request Code Billed Codes Names Codes Groupings Instrumentation: Microdiscectomy: +22840, +22841, 62380, 63030, +22842, +22845, +63035 +22853 ALIF, TLIF, 22533, 22558, Decompression: Bone Grafts: Lumbar Fusion PLIF, XLIF, 22612 22612, 22630, 63005, 63012, +20930, +20931, (Single Level) OLIF, Postero- 22633 63017, 63042, +20936, +20937, lateral fusion +63044, 63047, +20938 +63048, 63056, Bone Marrow +63057 Aspiration: +20939 Microdiscectomy: 62380, 63030, Instrumentation: +63035 +22840, +22841, Decompression: +22842, +22845, +22853 +22534, 63005, 63012, ALIF, TLIF, Bone Grafts: Lumbar Fusion +22585, 63017, 63042, PLIF, XLIF, 22614 +20930, +20931, (Multiple Levels) +22614, +63044, 63047, OLIF, Postero- +20936, +20937, +22632, +22634 +63048, 63056, lateral fusion +63057 +20938 Single Level Bone Marrow Fusion: 22533, Aspiration: 22558, 22612, +20939 22630, 22633 Sacroiliac joint Sacroiliac Joint arthrodesis, 27279 27279 Fusion (SIJ)4 Percutaneous SIJ Fusion

4 Effective for dates of service on or after October 1, 2021, NIA will review prior authorization requests for SIJ fusion with use of fixation devices only.

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CERVICAL SPINE SURGERY These codes do not require prior authorization. If the main surgical procedure is Authorization is provided for the primary surgery requested. approved, these codes are There are multiple CPT codes that can be associated with each understood to be procedure. These are assumed to be part of the primary surgery included in request and when completed in combination, do not require a separate conjunction and do prior authorization. not require prior authorization. Note: This is not an all-inclusive list of every ancillary code Primary Primary Primary Additional Ancillary Other Surgery CPT Surgery Covered Procedures / Procedure Request Code Allowable Procedures / Codes Names Billed Codes Groupings Cervical 63075 63075, +63076 Vertebral Instrumentation: Anterior Corpectomy: +22859 Decompression 63081, (without +63082, fusion) 63300, 63304, +63308 Anterior 22551 22548, 22551, Vertebral Instrumentation: ACDF Cervical 22554 Corpectomy: +22845, 22853, Decompression 63081, 22854 with Fusion +63082, Bone Grafts: (Single Level) 63300, 63304, +20930, +20931, +63308 +20936, +20937, Decompressio +20938 n: 63075, +63076 Removal of Artificial Disc: 22864 Anterior 22552 +22552, Vertebral Instrumentation: ACDF Cervical +22585 Corpectomy: +22845, +22846, Decompression 63081, 22853, 22854 with Fusion +63082, Bone Grafts: (Multiple 63300, 63304, 20930, +20931, Levels) +63308 +20936, +20937, Decompressio +20938 n: 63075, Bone Marrow +63076 Aspiration: Single-Level +20939 ACDF: 22548, 22551, 22554 Removal of Artificial Disc: 22864

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CERVICAL SPINE SURGERY These codes do not require prior authorization. If the main surgical procedure is Authorization is provided for the primary surgery requested. approved, these codes are There are multiple CPT codes that can be associated with each understood to be procedure. These are assumed to be part of the primary surgery included in request and when completed in combination, do not require a separate conjunction and do prior authorization. not require prior authorization. Note: This is not an all-inclusive list of every ancillary code Primary Primary Primary Additional Ancillary Other Surgery CPT Surgery Covered Procedures / Procedure Request Code Allowable Procedures / Codes Names Billed Codes Groupings Cervical 63045 63001, 63015, Lamino- Posterior 63020, +63035, foraminotomy, Decompression 63040, +63043, Laminectomy (without 63045, +63048, fusion) 63050, 63051 Cervical 22600 22590, 22595, Decompressio Instrumentation: Posterior Posterior 22600 n: 63001, +22840, +22841 fusion, Decompression 63015, 63020, Bone Grafts: Arthrodesis with Fusion +63035, +20930, +20931, (Single Level) 63040, +20936, +20937 +63043, 63045, +63048, 63050, 63051

Cervical 22595 +22595, Decompressio Instrumentation: Posterior Posterior +22614 n: 63001, +22840, +22841, fusion, Decompression 63015, 63020, +22842, +22843, Arthrodesis with Fusion +63035, +22844 (Multiple 63040, Bone Grafts: Levels) +63043, +20930, +20931, 63045, +20936, +20937 +63048, 63050, 63051 Single-Level Fusion: 22590, 22595, 22600 Cervical 22856 22856, 22861 Removal of Instrumentation: Disc Artificial Disc - Artificial Disc: 22845, 22853 replacement, Single Level 22864 Bone Grafts: Disc +20930, +20931, arthroplasty, +20936, +20937, CADR +20938

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OTHER PROCEDURES OR DEVICES No or limited evidence of effectiveness (considered noncovered investigational services) Procedure Name Primary CPT Code Allowable Billed Groupings Minimally Invasive Decompression 62287 62287, 0274T, 0275T (including MILD) Percutaneous Thermal Intra-Discal 22526 22526, +22527 Procedures (including IDET) Pre-Sacral/Axial Interbody Fusion 22586 22586

Add-on codes (prefixed with +) do not require separate authorizations and are to be used in conjunction with approved primary code for the service rendered. JOINT SURGERY² If a procedure from the allowable billed groupings is billed, and a valid authorization number for the corresponding authorized CPT procedure code has been issued within the date of service validity period, the service is eligible for coverage, subject to the provisions of the member’s benefit plan document. Note: Joint surgery services rendered as part of ED services are not subject to prior authorization. For procedures performed in an inpatient setting, inpatient notification is required from Tufts Health Plan in addition to the appropriate authorization.

HIP SURGERY Authorization is provided for the primary surgery requested. There are multiple CPT codes that can be associated with each procedure. These are

assumed to be part of the primary surgery request and when completed in combination, do not require a separate prior authorization. Primary Primary Surgery Additional Primary Surgery Other Procedure CPT Allowable Covered Request Names Code Billed Procedures/Codes Groupings Revision hip replacement, Revision/Conversion Hip 27132, 27134, 27134 Revision THA, Arthroplasty 27137, 27138 Revision THR, “Re- do” hip replacement Total hip Total Hip 27130 27130, S2118 replacement, THA, Arthroplasty/Resurfacing THR Loose Body Labral repair, Removal: 29861 Cartilage repair, Femoroacetabular 29914, 29915, Chondroplasty: CAM lesion, Pincer Impingement (FAI) Hip 29914 29916 29862 lesion, Surgery Synovectomy: Acetabuloplasty, 29863 Femoroplasty Diagnostic arthroscopy, Synovectomy, Loose 29860, 29861, 29863 body removal, Hip Surgery (Other) 29862, 29863 Debridement, Chondroplasty, Hip scope

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KNEE SURGERY Authorization is provided for the primary surgery requested. There are multiple CPT codes that can be associated with each procedure. These are assumed to be part of the primary surgery request and when completed in combination, do not require a separate prior authorization. Primary Primary Surgery Additional Primary Surgery Other Procedure CPT Allowable Covered Request Names Code Billed Procedures/Codes Groupings Revision knee replacement, Revision Revision Knee 27487 27486, 27487 TKA, Revision TKR, Arthroplasty “Re-do” knee replacement Total Knee Total knee 27447 27447 Arthroplasty (TKA) replacement, TKA, TKR Partial- Partial knee Unicompartmental replacement, 27446 2746, 27438 Knee Arthroplasty Unicondylar knee (UKA) replacement Knee Manipulation Lysis of adhesions, under Anesthesia 27570 27570, 29884 Scar tissue removal (MUA) Meniscectomy: 27332, 27333, 27403, 29868, 29880, 29881, 29882, 29883 Autologous chondrocyte implantation: 27412 Anterior cruciate Osteochondral ligament (ACL), Allograft/Autograft: Posterior cruciate 27415, 27416, ligament (PCL), Medial 27405, 27407, 29866, 29867 collateral ligament Knee Ligament 27409, 27427, 29888 Anterior tibial (MCL), Lateral Reconstruction/Repair 27428, 27429, tubercleplasty: collateral ligament 29888, 29889 27418 (LCL), Medial Reconstruction of Patellofemoral Dislocating Patella: Ligament (MPFL), 27420, 27422, Dislocating patella 27424 Lateral Release: 27425, 29873 Chondroplasty: 29877 Microfracture: 29879

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KNEE SURGERY Authorization is provided for the primary surgery requested. There are multiple CPT codes that can be associated with each procedure. These are assumed to be part of the primary surgery request and when completed in combination, do not require a separate prior authorization. Primary Primary Surgery Additional Primary Surgery Other Procedure CPT Allowable Covered Request Names Code Billed Procedures/Codes Groupings Autologous chondrocyte implantation: 27412 Osteochondral Allograft/Autograft: 27415, 27416, 29866, 29867 Anterior tibial tubercleplasty: 27418 Knee 27332, 27333, Reconstruction of Meniscectomy/Menisc 27403, 29868, Dislocating Patella: 29880 al Repair/Meniscal 29880, 29881, 27420, 27422, Transplant 29882, 29883 27424 Lateral Release: 27425, 29873 Loose Body Removal: 29874 Synovectomy: 29875, 29876 Chondroplasty: 29877 Microfracture: 29879, G0289 Diagnostic arthroscopy, Autologous chondrocyte 27412, 27415, implantation, 27416, 27418, Osteochondral 27420, 27422, Allograft/Autograft, 27424, 27425, Anterior tibial Knee Surgery (Other) 29879 29866, 29867, tubercleplasty, 29870, 29873, Reconstruction of 29874, 29875, Dislocating Patella, 29876, 29877, Lateral Release, Loose 29879, G0289 Body Removal, Synovectomy, Chondroplasty, Microfracture

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SHOULDER SURGERY Authorization is provided for the primary surgery requested. There are multiple CPT codes that can be associated with each procedure. These are

assumed to be part of the primary surgery request and when completed in combination, do not require a separate authorization. Primary Primary Surgery Additional Primary Surgery Other Procedure CPT Allowable Covered Request Names Code Billed Procedures/Codes Groupings Revision shoulder replacement, Revision Revision Shoulder 23474 23473, 23474 TSA, Revision TSR, Arthroplasty “Re-do” shoulder replacement Total/Reverse Total shoulder Shoulder Arthroplasty 23472 23472 replacement, TSA, TSR or Resurfacing Partial Shoulder Partial shoulder Arthroplasty/Hemiarth 23470 23470 replacement roplasty Frozen Shoulder Lysis of adhesions, Manipulation under Repair/Adhesive 29825 29825 Capsular release, Anesthesia: 23700 Capsulitis Break up scar tissue Claviculectomy: 23120, 23125 Acromioplasty: 23130 Coracoacromial ligament release: 23415 Biceps Tenotomy/Tenodesis SLAP repair, Bankart 23450, 23455, : 23405, 23430, repair (can include Shoulder Labral 23460, 23462, Remplissage 29806 29828 Repair 23465, 23466, procedure), Synovectomy: 29806, 29807 Capsulorrhaphy, 29820, 29821 Latarjet procedure Debridement: 29822, 29823 Distal Clavicle Excision (Mumford procedure): 29824 Subacromial Decompression: 29826

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SHOULDER SURGERY Authorization is provided for the primary surgery requested. There are multiple CPT codes that can be associated with each procedure. These are

assumed to be part of the primary surgery request and when completed in combination, do not require a separate authorization. Primary Primary Surgery Additional Primary Surgery Other Procedure CPT Allowable Covered Request Names Code Billed Procedures/Codes Groupings Claviculectomy: 23120, 23125 Acromioplasty: 23130 Coracoacromial ligament release: 23415 Biceps Tenotomy/Tenodesis : 23405, 23430, Arthroscopic superior Shoulder Rotator Cuff 23410, 23412, 29827 29828 capsular Repair 23420, 29827 Synovectomy: reconstruction 29820, 29821 Debridement: 29822, 29823 Distal Clavicle Excision (Mumford procedure): 29824 Subacromial Decompression: 29826 Diagnostic arthroscopy, Claviculectomy, 23120, 23125, Acromioplasty, 23130, 23405, Coracoacromial 23415, 23430, ligament release, 23700, 29805, Shoulder Surgery - Biceps 23415 29819, 29820, Other Tenotomy/Tenodesis, 29821, 29822, Synovectomy, 29823, 29824, Debridement, Distal 29825, 29826, Clavicle Excision 29828 (Mumford procedure), Subacromial Decompression

Note: • Unspecified procedure codes (e.g., 23929, 29999) must be reviewed and approved through the Tufts Health Plan appeals process. Refer to the Provider Payment Dispute Policy for more information. • If any joint surgery is to be performed bilaterally (modifier 50) on the same date of service, separate authorizations are required for each joint. • The following procedures are considered to be Noncovered Investigational and are not reimbursable:

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– CPT codes G0428 (collagen meniscus implant procedure for filling meniscal defects [e.g., CMI, collagen scaffold, Menaflex]) and S2300 (arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy) – CPT code S2300 Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy – Knee Arthroscopy: Subchondroplasty and In-Office diagnostic arthroscopy (Vision Scope, Mi-eye) – Shoulder Arthroscopy: in-office diagnostic arthroscopy (VisionScope, Mi-Eye) and US guided percutaneous debridement or tenotomy (e.g. Tenex) Refer to the Noncovered Investigational Services Medical Necessity Guidelines for more information. AUDIT AND DISCLAIMER INFORMATION Tufts Health Plan reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in this payment policy. If such an audit determines that a provider/facility did not comply with this payment policy, Tufts Health Plan will expect the provider/facility to refund all payments related to noncompliance. For more information about Tufts Health Plan’s audit policies, refer to the public Provider website. This policy provides information on Tufts Health Plan claims adjudication processes. As every claim is unique, this policy is neither a guarantee of payment, nor a final indication of how specific claim(s) will be adjudicated. Claims payment is subject to member eligibility and benefits on the date of service, coordination of benefits, referral/authorization and utilization management requirements (when applicable), adherence to plan policies and procedures, and claims editing logic. An authorization is not a guarantee of payment. Claims for services subject to authorization may be reviewed for accuracy and compliance with payment policies. This policy applies to the Tufts Health Plan products, as identified in the checkboxes on the first page, and to CareLinkSM for providers in Massachusetts and Rhode Island service areas. Providers in the New Hampshire service area are subject to Cigna’s provider agreements with respect to CareLink members. This policy does not apply to the Private Health Care Systems (PHCS) network (also known as Multiplan). Tufts Health Plan reserves the right to amend a payment policy at its discretion.

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