Spinal Interventional Pain Management and Lumbar Spine Surgery

Policy Number: Original Effective Date: MM.06.024 01/01/2014 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 12/15/2017 Section: Surgery; Medicine Place(s) of Service: Office; Outpatient; Inpatient

I. Description The following spinal interventional pain management and lumbar spine surgery procedures require precertification through Magellan Hawaii, formally known as National Imaging Associates, Inc. (NIA): A. Spinal Epidural Injections B. Paravertebral Facet Joint Denervation (radiofrequency neurolysis) C. Paravertebral Facet Joint Injections or Blocks D. Sacroiliac joint injections E. Lumbar Spinal Fusion Surgery

II. Administrative Guidelines A. The ordering physician can obtain precertification or consult with Magellan Hawaii by accessing their website at http://www.radmd.com/ or by calling 1 (866) 306-9729, from 6 a.m. to 6 p.m., weekdays, Hawaii Time. Refer to the e-library for instructions on navigating the radmd.com website (RadMD Get Started) and requesting precertification/checking the status of a request (RadMD QuickStart). B. For access to the latest clinical guidelines used for precertification, go to www.radmd.com and click on the link entitled View Clinical Guidelines. C. For interventional pain management procedures (epidural injections, facet joint denervation neurolysis, facet joint injections and sacroiliac joint injections), if more than one procedure is planned, a separate precertification number must be obtained for each procedure planned. D. For spinal surgeries (lumbar fusions, lumbar decompressions, and lumbar microdiscectomy), one precertification number should be obtained for the most invasive surgery to be performed. E. Precertification requirements for injection procedures apply only to office and outpatient services (POS 11, 22, or 24). Services performed in connection with an emergency department visit or observation room confinement (POS 23) and services rendered during an inpatient stay (POS 21) do not require precertification. F. Precertification is not required for services ordered for FEP members. G. Codes that require precertification: Spinal Interventional Pain Management and Lumbar Spine Surgery 2

1. Spinal epidural injections: Cervical/Thoracic Region CPT Code Description 0228T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level 0229T each additional level (List separately in addition to code for primary procedure) 62320 Injection(s), of diagnostic or therapeutic substance(s) (e.g. Anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging 62321 Injection(s), of diagnostic or therapeutic substance(s) (e.g. Anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging 64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level 64480 cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

Lumbar/Sacral Region CPT Code Description 0230T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level 0231T each additional level (List separately in addition to code for primary procedure) 62322 Injection(s), of diagnostic or therapeutic substance(s) (e.g. Anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (cauda); without imaging 62323 Injection(s), of diagnostic or therapeutic substance(s) (e.g. Anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (cauda); with imaging 64483 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level 64484 lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

Spinal Interventional Pain Management and Lumbar Spine Surgery 3

2. Paravertebral facet joint denervation (radiofrequency neurolysis): Cervical/Thoracic region

CPT Code Description 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint 64634 cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)

Lumbar/Sacral region

CPT Code Description 64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint 64636 lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

3. Paravertebral facet joint injections or blocks: Cervical/Thoracic region

CPT Code Description 0213T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level 0214T second level (List separately in addition to code for primary procedure) 0215T third and any additional level(s) (List separately in addition to code for primary procedure) 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level 64491 second level (List separately in addition to code for primary procedure) 64492 third and any additional level(s) (List separately in addition to code for primary procedure)

Lumbar/Sacral region

CPT Codes Description 0216T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level 0217T second level (List separately in addition to code for primary procedure) 0218T third and any additional level(s) (List separately in addition to code for primary procedure) 64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet Spinal Interventional Pain Management and Lumbar Spine Surgery 4

(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 64494 second level (List separately in addition to code for primary procedure) 64495 third and any additional level(s) (List separately in addition to code for primary procedure)

4. Sacroiliac joint injections:

CPT Codes Description 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

HCPCS Description Codes G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography (this code is to be billed by facilities only)

5. Lumbar spinal fusion surgery: Lumbar Fusion (single level)

CPT Codes Description 22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar 22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) 22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar 22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar

ICD-10-PCS Codes Description 0SG0071, 0SG00A1, Fusion of lumbar vertebral joint, posterior approach, posterior 0SG00J1, 0SG00K1, column, open approach, code by device 0SG00Z1 0SG0371, 0SG03A1, Fusion of lumbar vertebral joint, posterior approach, posterior 0SG03J1, 0SG03K1, column, percutaneous approach, code by device Spinal Interventional Pain Management and Lumbar Spine Surgery 5

0SG03Z1 0SG0471, 0SG04A1, Fusion of lumbar vertebral joint, posterior approach, posterior 0SG04J1, 0SG04K1, column, percutaneous endoscopic approach, code by device 0SG04Z1 0SG1071, 0SG10A1, Fusion of lumbar vertebral joints, posterior approach, posterior 0SG10J1, 0SG10K1, column, open approach, code by device 0SG10Z1 0SG1371, 0SG13A1, Fusion of 2 or more lumbar vertebral joints, posterior approach, 0SG13J1, 0SG13K1, posterior column, percutaneous approach, code by device 0SG13Z1 0SG1471, 0SG14A1, Fusion of 2 or more lumbar vertebral joints, posterior approach, 0SG14J1, 0SG14K1, posterior column, percutaneous endoscopic approach, code by 0SG14Z1 device 0SG3071, 0SG30A1, Fusion of lumbosacral joint, posterior approach, posterior 0SG30J1, 0SG30K1, column, open approach, code by device 0SG30Z1 0SG3371, 0SG33A1, Fusion of lumbosacral joint, posterior approach, posterior 0SG33J1, 0SG33K1, column, percutaneous approach, code by device 0SG33Z1 0SG3471, 0SG34A1, Fusion of lumbosacral joint, posterior approach, posterior 0SG34J1, 0SG34K1, column, percutaneous endoscopic approach, code by device 0SG34Z1

Lumbar Fusion (multiple levels)

CPT Codes Description 22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar 22534 thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure) 22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar 22585 each additional interspace (List separately in addition to code for primary procedure) 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) 22614 each additional vertebral segment (List separately in addition to code for primary (procedure) 22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar 22632 each additional interspace (List separately in addition to code for (primary procedure) Spinal Interventional Pain Management and Lumbar Spine Surgery 6

22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar 22634 each additional interspace and segment (List separately in addition to code for primary procedure)

Lumbar Decompression

CPT Codes Description 62380 Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar 63005 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis 63012 Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) 63017 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), more than 2 vertebral segments; lumbar 63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar 63035 each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure 63042 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar 63044 each additional lumbar interspace (List separately in addition to code for primary procedure) 63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; lumbar 63048 each additional segment, cervical, thoracic, or lumbar 63056 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (e.g., far lateral herniated intervertebral disc) 63057 each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure)

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ICD-10-PCS Description 009T00Z, 009T0ZZ Drainage of spinal meninges, open approach, code by device 009T30Z, 009T3ZZ Drainage of spinal meninges, percutaneous approach, code by device 009T40Z, 009T4ZZ Drainage of spinal meninges, endoscopic approach, code by device 009U00Z, 009U0ZZ Drainage of spinal canal, open approach, code by device 009W00Z, 009W0ZZ Drainage of cervical spinal cord, open approach, code by device 009W30Z, 009W3ZZ Drainage of cervical spinal cord, percutaneous approach, code by device 009W40Z, 009W4ZZ Drainage of cervical spinal cord, percutaneous endoscopic approach, code by device 009X00Z, 009X0ZZ Drainage of thoracic spinal cord, open approach, code by device 009X30Z, 009X3ZZ Drainage of thoracic spinal cord, percutaneous approach, code by device 009X40Z, 009X4ZZ Drainage of thoracic spinal cord, percutaneous endoscopic approach, code by device 009Y00Z, 009Y0ZZ Drainage of lumbar spinal cord, open approach, code by device 009Y30Z, 009Y3ZZ Drainage of lumbar spinal cord, percutaneous approach, code by device 009Y40Z, 009Y4ZZ Drainage of lumbar spinal cord, percutaneous endoscopic approach, code by device 00JU0ZZ, 00JV0ZZ Inspection, open approach, code by body part (spinal canal or cord) 00NW0ZZ, 00NW3ZZ, Release cervical spinal cord, code by approach 00NW4ZZ 00NX0ZZ, 00NX3ZZ, Release thoracic spinal cord, code by approach 00NX4ZZ 00NY0ZZ, 00NY3ZZ, Release lumbar spinal cord, code by approach 00NY4ZZ 0RB00ZZ, 0RB03ZZ, Excision of occipital-cervical joint, code by approach 0RB04ZZ 0RB10ZZ, 0RB13ZZ, Excision of cervical vertebral joint, code by approach 0RB14ZZ 0RB30ZZ, 0RB33ZZ, Excision of cervical vertebral disc, code by approach 0RB34ZZ 0RB40ZZ, 0RB43ZZ, Excision of cervicothoracic vertebral joint, code by approach 0RB44ZZ 0RB50ZZ, 0RB53ZZ, Excision of cervicothoracic vertebral disc, code by approach 0RB54ZZ 0RB60ZZ, 0RB63ZZ, Excision of thoracic vertebral joint, code by approach 0RB64ZZ Spinal Interventional Pain Management and Lumbar Spine Surgery 8

0RB90ZZ, 0RB93ZZ, Excision of thoracic vertebral disc, code by approach 0RB94ZZ 0RBA0ZZ, 0RBA3ZZ, Excision of thoracolumbar vertebral joint, code by approach 0RBA4ZZ 0RBB0ZZ, 0RBB3ZZ, Excision of thoracolumbar vertebral disc, code by approach 0RBB4ZZ 0RT30ZZ, 0RT40ZZ, Resection, code by body part (cervical vertebral disc, 0RT50ZZ, 0RT90ZZ, cervicothoracic vertebral joint, cervicothoracic vertebral disc, 0RTB0ZZ thoracic vertebral disc, or thoracolumbar vertebral disc) 0SB00ZZ, 0SB03ZZ, Excision of lumbar vertebral joint, code by approach 0SB04ZZ 0SB20ZZ, 0SB23ZZ, Excision of lumbar vertebral disc, code by approach 0SB24ZZ 0SB30ZZ, 0SB33ZZ, Excision of lumbosacral joint, code by approach 0SB34ZZ 0SB40ZZ, 0SB43ZZ, Excision of lumbosacral disc, code by approach 0SB44ZZ 0SB50ZZ, 0SB53ZZ, Excision of sacrococcygeal joint, code by approach 0SB54ZZ 0SB60ZZ, 0SB63ZZ, Excision of coccygeal joint, code by approach 0SB64ZZ 0SB70ZZ, 0SB73ZZ, Excision of right sacroiliac joint, code by approach 0SB74ZZ 0SB80ZZ, 0SB83ZZ, Excision of left sacroiliac joint, code by approach 0SB84ZZ 0ST20ZZ, 0ST40ZZ Excision, open approach, code by body part (lumbar vertebral or lumbosacral disc)

Lumbar Microdiscectomy

CPT Codes Description 63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar 63035 each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure) 62380 Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar.

ICD-10-PCS Codes Description 0RB30ZZ, 0RB33ZZ, Excision of cervical vertebral disc, code by approach 0RB34ZZ

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0RB50ZZ, 0RB53ZZ, Excision of cervicothoracic vertebral disc, code by approach 0RB54ZZ 0RB90ZZ, 0RB93ZZ, Excision of thoracic vertebral disc, code by approach 0RB94ZZ 0RBB0ZZ, 0RBB3ZZ, Excision of thoracolumbar vertebral disc, code by approach 0RBB4ZZ 0RT30ZZ, 0RT40ZZ, Resection, open approach, code by body part (cervical vertebral 0RT50ZZ, 0RT90ZZ, disc, cervicothoracic vertebral joint, cervicothoracic vertebral 0RTB0ZZ disc, thoracic vertebral disc, or thoracolumbar vertebral disc) 0SB20ZZ, 0SB23ZZ, Excision of lumbar vertebral disc, code by approach 0SB24ZZ 0SB40ZZ, 0SB43ZZ, Excision of lumbosacral disc, code by approach 0SB44ZZ 0ST20ZZ, 0ST40ZZ Resection, open approach, code by body part (cervical vertebral disc, cervicothoracic vertebral joint, cervicothoracic vertebral disc, thoracic vertebral disc, or thoracolumbar vertebral disc)

III. Limitations Lumbar artificial disc replacement and pre-sacral fusion are not covered due to a lack of published studies showing that these procedures improve health outcomes over current standard therapies. Codes representing these procedures include the following:

A. Lumbar artificial disc replacement CPT Codes Description 0163T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional space interspace, lumbar (List separately in addition to code for primary procedure) 0165T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure) 0221T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar 0222T each additional vertebral segment (list separately in addition to code for primary procedure) 22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar 22862 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar

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22865 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar

B. Pre-Sacral Fusion CPT Codes Description 0195T Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L5-S1 interspace 0196T L4-L5 interspace (List separately in addition to code for primary procedure) 0309T Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (List separately in addition to code for the primary procedure) 22586 Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace