Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

ACL Repair 27407 Repair, primary, torn ligament and/or capsule, knee; cruciate

ACL Repair 27409 Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments

ACL Repair 29888 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction

Acromioplasty and Rotator Cuff Repair 23130 Acromioplasty Or Acromionectomy, Partial, With Or Without Coracoacromial Ligament Release

Acromioplasty and Rotator Cuff Repair 23410 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute

Acromioplasty and Rotator Cuff Repair 23412 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic

Acromioplasty and Rotator Cuff Repair 23415 Coracoacromial Ligament Release, With Or Without Acromioplasty

Acromioplasty and Rotator Cuff Repair 23420 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)

Arthroscopy, Shoulder, Surgical; Decompression Of Subacromial Space With Partial Acromioplasty, With Coracoacromial Ligament (Ie, Arch) Release, When Performed (List Separately Acromioplasty and Rotator Cuff Repair 29826 In Addition To Code For Primary Procedure)

Acromioplasty and Rotator Cuff Repair 29827 Arthroscopy, shoulder, surgical; with rotator cuff repair

Allograft for Spinal Fusion [BMP] 20930 Allograft, morselized, or placement of osteopromotive material, for spine surgery only

Ankle Fusion 27870 Arthrodesis, ankle, open

Ankle Fusion 29899 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and Cervical Disc Replacement 22856 microdissection), single interspace, cervical

Cervical Disc Replacement 22861 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical

Cervical Disc Replacement 22864 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and excision of herniated intervertebral disc, and repair of Cervical Laminectomy and Discectomy C9757 annular defect with implantation of bone anchored annular closure device, including annular defect measurement, alignment and sizing assessment, and image guidance; 1 interspace, lumbar Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral Cervical Laminectomy and Discectomy 63001 segments; cervical

Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 Cervical Laminectomy and Discectomy 63015 vertebral segments; cervical

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, Cervical Laminectomy and Discectomy 63020 cervical

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, Cervical Laminectomy and Discectomy 63040 single interspace; cervical

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), Cervical Laminectomy and Discectomy 63045 single vertebral segment; cervical

Cervical Laminectomy and Discectomy 63050 Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments

Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging Cervical Laminectomy and Discectomy 63051 bone graft and non-segmental fixation devices (eg, wire, suture, mini-plates), when performed)

Cervical Laminectomy and Discectomy 63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace

Cervical Laminectomy and Discectomy 63076 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace

Cervical Laminectomy and Discectomy 63180 Laminectomy and section of dentate ligaments, with or without dural graft, cervical; 1 or 2 segments

Cervical Laminectomy and Discectomy 63182 Laminectomy and section of dentate ligaments, with or without dural graft, cervical; more than 2 segments

Cervical Laminectomy and Discectomy 63194 Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 stage; cervical

Cervical Laminectomy and Discectomy 63196 Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage; cervical

Cervical Laminectomy and Discectomy 63198 Laminectomy with cordotomy with section of both spinothalamic tracts, 2 stages within 14 days; cervical

Cervical Laminectomy and Discectomy 63250 Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; cervical

Cervical Laminectomy and Discectomy 63265 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Cervical Laminectomy and Discectomy 63270 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical

Cervical Laminectomy and Discectomy 63275 Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical

Cervical Laminectomy and Discectomy 63280 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, cervical

Cervical Laminectomy and Discectomy 63285 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical

Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or Cervical Laminectomy and Discectomy 0274T foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic

Cervical Spinal Fusion 22548 Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process

Cervical Spinal Fusion 22551 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2

Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each Cervical Spinal Fusion 22552 additional interspace (List separately in addition to code for separate procedure)

Cervical Spinal Fusion 22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2

Cervical Spinal Fusion 22590 Arthrodesis, posterior technique, craniocervical (occiput-C2)

Cervical Spinal Fusion 22595 Arthrodesis, posterior technique, atlas-axis (C1-C2)

Cervical Spinal Fusion 22600 Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment

Elbow Replacement 24160 Removal of prosthesis, includes debridement and synovectomy when performed; humeral and ulnar components

Elbow Replacement 24164 Removal of prosthesis, includes debridement and synovectomy when performed; radial head

Elbow Replacement 24360 Arthroplasty, elbow; with membrane (e.g., fascial)

Elbow Replacement 24361 Arthroplasty, elbow; with distal humeral prosthetic replacement

Elbow Replacement 24362 Arthroplasty, elbow; with implant and fascia lata ligament reconstruction Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Elbow Replacement 24363 Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (e.g., total elbow)

Elbow Replacement 24365 Arthroplasty, radial head

Elbow Replacement 24366 Arthroplasty, radial head; with implant

Elbow Replacement 24370 Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar component

Elbow Replacement 24371 Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar component

Femoroacetabular Arthroscopy 27299 Unlisted procedure, pelvis or hip joint [when specified as open procedure for femoroacetabular impingement syndrome, other than capsular plication]

Femoroacetabular Arthroscopy 29914 Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion)

Femoroacetabular Arthroscopy 29915 Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion)

Femoroacetabular Arthroscopy 29916 Arthroscopy, hip, surgical; with labral repair [when repair of the labral tear is associated with FAIS]

Hip Arthroscopy 29860 Arthroscopy, Hip, Diagnostic With Or Without Synovial Biopsy (Separate Procedure)

Hip Arthroscopy 29861 Arthroscopy, Hip, Surgical; With Removal Of Loose Body Or Foreign Body

Hip Arthroscopy 29862 Arthroscopy, Hip, Surgical; With Debridement/Shaving Of Articular Cartilage (Chondroplasty), Abrasion Arthroplasty, And/Or Resection Of Labrum

Hip Arthroscopy 29863 Arthroscopy, Hip, Surgical; With Synovectomy

Hip Resurfacing 27033 Arthrotomy, hip, including exploration or removal of loose or foreign body

Hip Resurfacing 27125 Hip Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)

Implantable Infusion Pumps 36260 Insertion of implantable intra-arterial infusion pump (eg, for chemotherapy of liver)

Implantable Infusion Pumps 36563 Insertion Of Tunneled Centrally Inserted Central Venous Access Device With Subcutaneous Pump Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Implantable Infusion Pumps 36583 Replacement, Complete, Of A Tunneled Centrally Inserted Central Venous Access Device, With Subcutaneous Pump, Through Same Venous Access

Implantable Infusion Pumps 61215 Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter

Implantation, Revision Or Repositioning Of Tunneled Intrathecal Or Epidural Catheter, For Long-Term Medication Administration Via An External Pump Or Implantable Implantable Infusion Pumps 62350 Reservoir/Infusion Pump; Without Laminectomy

Implantable Infusion Pumps 62360 Implantation Or Replacement Of Device For Intrathecal Or Epidural Drug Infusion; Subcutaneous Reservoir

Implantable Infusion Pumps 62361 Implantation Or Replacement Of Device For Intrathecal Or Epidural Drug Infusion; Nonprogrammable Pump

Implantable Infusion Pumps 62362 Implantation Or Replacement Of Device For Intrathecal Or Epidural Drug Infusion; Programmable Pump, Including Preparation Of Pump, With Or Without Programming

Implantable Infusion Pumps 62365 Removal Of Subcutaneous Reservoir Or Pump, Previously Implanted For Intrathecal Or Epidural Infusion

Electronic Analysis Of Programmable, Implanted Pump For Intrathecal Or Epidural Drug Infusion (Includes Evaluation Of Reservoir Status, Alarm Status, Drug Prescription Status); Implantable Infusion Pumps 62367 Without Reprogramming Or Refil

Electronic Analysis Of Programmable, Implanted Pump For Intrathecal Or Epidural Drug Infusion (Includes Evaluation Of Reservoir Status, Alarm Status, Drug Prescription Status); With Implantable Infusion Pumps 62368 Reprogramming

Implantable Infusion Pumps C1772 Infusion pump, programmable (implantable)

Implantable Infusion Pumps C1891 Infusion pump, nonprogrammable, permanent (implantable)

Implantable Infusion Pumps C2626 Infusion pump, nonprogrammable, temporary (implantable)

Implantable Infusion Pumps E0783 Infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.)

Implantable Infusion Pumps E0785 Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement

Implantable Infusion Pumps E0786 Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter)

Knee Arthroscopy 27405 Repair, primary, torn ligament and/or capsule, knee; collateral Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Knee Arthroscopy 29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)

Knee Arthroscopy 29871 Arthroscopy, knee, surgical; for infection, lavage and drainage

Knee Arthroscopy 29873 Arthroscopy, knee, surgical; with lateral release

Knee Arthroscopy 29874 Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)

Knee Arthroscopy 29875 Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)

Knee Arthroscopy 29876 Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral)

Knee Arthroscopy 29877 Arthroscopy, knee, surgical; debridement/ shaving or articular cartilage (chondroplasty)

Knee Arthroscopy 29879 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture

Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/ shaving of articular cartilage (chondroplasty), same or Knee Arthroscopy 29880 separate compartment(s), when performed

Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/ shaving of articular cartilage (chondroplasty), same or Knee Arthroscopy 29881 separate compartment(s), when performed

Knee Arthroscopy 29884 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure)

Knee Arthroscopy 29885 Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixaiton (including debridement of base of lesion)

Knee Arthroscopy 29886 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion

Knee Arthroscopy 29887 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation

Knee Arthroscopy 29889 ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ

Knee Arthroscopy 29999 Unlisted procedure, arthroscopy [when specified as arthroscopic knee lavage as a separate procedure]

Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a Knee Arthroscopy G0289 different compartment of the same knee Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Kyphoplasty and Vertebroplasty 22510 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic

Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral [when specified Kyphoplasty and Vertebroplasty 22511 as lumbar]

Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional Kyphoplasty and Vertebroplasty 22512 cervicothoracic or lumbosacral vertebral body [when specified as other than sacral]

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral Kyphoplasty and Vertebroplasty 22513 body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral Kyphoplasty and Vertebroplasty 22514 body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral Kyphoplasty and Vertebroplasty 22515 body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body

Kyphoplasty and Vertebroplasty 0200T Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles

Kyphoplasty and Vertebroplasty 0201T Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles

Posterior vertebral joint(s) arthroplasty (eg, facet joint[s] replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, Kyphoplasty and Vertebroplasty 0202T when performed, including fluoroscopy, single level, lumbar spine

Laminectomy- Unspecified 63170 Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar

Laminectomy- Unspecified 63172 Laminectomy with drainage of intramedullary cyst/syrinx; to subarachnoid space

Laminectomy- Unspecified 63173 Laminectomy with drainage of intramedullary cyst/syrinx; to peritoneal or pleural space

Laminectomy- Unspecified 63185 Laminectomy with rhizotomy; 1 or 2 segments

Laminectomy- Unspecified 63190 Laminectomy with rhizotomy; more than 2 segments

Laminectomy- Unspecified 63191 Laminectomy with section of spinal accessory nerve

Lumbar Disc Replacement 22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar

Lumbar Disc Replacement 22862 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Lumbar Disc Replacement 22865 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace, lumbar

Lumbar Disc Replacement 0163T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional interspace, lumbar

Lumbar Disc Replacement 0164T Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure)

Lumbar Disc Replacement 0165T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar

Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging Lumbar Laminectomy, Discectomy, and Laminotomy 62287 or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral Lumbar Laminectomy, Discectomy, and Laminotomy 63003 segments; thoracic

Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis) 1 or 2 vertebral Lumbar Laminectomy, Discectomy, and Laminotomy 63005 segments; lumbar, except for spondylolisthesis

Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral Lumbar Laminectomy, Discectomy, and Laminotomy 63011 segments; sacral

Lumbar Laminectomy, Discectomy, and Laminotomy 63012 Laminectomy with removal of abnormal facets and/or pars interarticularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)

Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 Lumbar Laminectomy, Discectomy, and Laminotomy 63016 vertebral segments; thoracic

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional Lumbar Laminectomy, Discectomy, and Laminotomy 63035 interspace, cervical or lumbar

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, re-exploration, Lumbar Laminectomy, Discectomy, and Laminotomy 63042 single interspace; lumbar

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), Lumbar Laminectomy, Discectomy, and Laminotomy 63046 single vertebral segment; thoracic

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), Lumbar Laminectomy, Discectomy, and Laminotomy 63047 single vertebral segment; lumbar Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), Lumbar Laminectomy, Discectomy, and Laminotomy 63048 single vertebral segment; each additional segment, cervical, thoracic, or lumbar

Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral Lumbar Laminectomy, Discectomy, and Laminotomy 63056 extraforaminal approach) (eg, far lateral herniated intervertebral disc)

Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or Lumbar Laminectomy, Discectomy, and Laminotomy 63057 lumbar [when specified as lumbar]

Lumbar Laminectomy, Discectomy, and Laminotomy 63200 Laminectomy, with release of tethered spinal cord, lumbar

Lumbar Laminectomy, Discectomy, and Laminotomy 63252 Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar

Lumbar Laminectomy, Discectomy, and Laminotomy 63267 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar

Lumbar Laminectomy, Discectomy, and Laminotomy 63272 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar

Lumbar Laminectomy, Discectomy, and Laminotomy 63277 Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar

Lumbar Laminectomy, Discectomy, and Laminotomy 63282 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar

Lumbar Laminectomy, Discectomy, and Laminotomy 63287 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracolumbar

Lumbar Laminectomy, Discectomy, and Laminotomy 63290 Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural lesion, any level [when specified as lumbar]

Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, lumbar or sacral by transperitoneal or Lumbar Laminectomy, Discectomy, and Laminotomy 63303 retroperitoneal approach

Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or Lumbar Laminectomy, Discectomy, and Laminotomy 0275T foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar

Lumbar Spinal Fusion 22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

Lumbar Spinal Fusion 22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, Lumbar Spinal Fusion 22586 L5-S1 interspace

Lumbar Spinal Fusion 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Lumbar Spinal Fusion 22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other Lumbar Spinal Fusion 22633 than for decompression), single interspace and segment; lumbar

Meniscal Repair and Allograft Transplantation 29868 Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral

Meniscal Repair and Allograft Transplantation 29882 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral)

Meniscal Repair and Allograft Transplantation 29883 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral)

Osteochondral Defect Repair 27412 Autologous chondrocyte implantation, knee

Osteochondral Defect Repair 27415 Osteochondral allograft, knee, open [when specified as osteochondral allograft]

Osteochondral Defect Repair 27416 Osteochondral autograft(s), knee, open (eg, mosaicplasty) includes harvesting of autograft[s])

Osteochondral Defect Repair 29866 Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft)

Osteochondral Defect Repair 29867 Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty)

Osteochondral Defect Repair J7330 Autologous cultured chondrocytes, implant

Partial Knee Replacement 27437 Arthroplasty, patella; without prosthesis

Partial Knee Replacement 27438 Arthroplasty, patella; with prosthesis

Partial Knee Replacement 27440 Arthroplasty, knee, tibial plateau;

Partial Knee Replacement 27441 Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy

Partial Knee Replacement 27442 Arthroplasty, femoral condyles or tibial plateau(s), knee;

Partial Knee Replacement 27443 Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Partial Knee Replacement 27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment

Revision of Total Hip Replacement 27090 Removal of hip prothesis

Revision of Total Hip Replacement 27091 Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacer

Revision of Total Hip Replacement 27134 Hip Revision of total hip arthroplasty; both components, with or without autograft or allograft

Revision of Total Hip Replacement 27137 Hip Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft

Revision of Total Hip Replacement 27138 Hip Revision of total hip arthroplasty; femoral component only, with or without allograft

Revision of Total Knee Replacement 27486 Revision of total knee arthroplasty, with or without allograft; 1 component

Revision of Total Knee Replacement 27487 Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component

Revision of Total Knee Replacement 27488 Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee

Sacral Decompression 63268 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral

Sacroiliac Joint Fusion 27280 Arthrodesis, sacroiliac joint (including obtaining graft)

Shoulder Fusion 23800 Arthrodesis, glenohumeral joint;

Shoulder Fusion 23802 Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft)

Shoulder Replacement (Total, Reverse, Revision, Hemi) 23333 Removal of foreign body, shoulder; deep (subfascial or intramuscular)

Shoulder Replacement (Total, Reverse, Revision, Hemi) 23334 Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid component

Shoulder Replacement (Total, Reverse, Revision, Hemi) 23335 Removal of prosthesis, includes debridement and synovectomy when performed; humeral and glenoid components (eg, total shoulder)

Shoulder Replacement (Total, Reverse, Revision, Hemi) 23470 Arthroplasty, glenohumeral joint; hemiarthroplasty Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Shoulder Replacement (Total, Reverse, Revision, Hemi) 23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (e.g., total shoulder)

Shoulder Replacement (Total, Reverse, Revision, Hemi) 23473 Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component

Shoulder Replacement (Total, Reverse, Revision, Hemi) 23474 Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component

Open Treatment Of Proximal Humeral (Surgical Or Anatomical Neck) Fracture, Includes Internal Fixation, When Performed, Includes Repair Of Tuberosity(S), When Performed; With Shoulder Replacement (Total, Reverse, Revision, Hemi) 23616 Proximal Humeral Prosthetic Replacement

Spinal Cord Neurostimulator 63650 Percutaneous implantation of neurostimulator electrode array, epidural

Spinal Cord Neurostimulator 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural

Spinal Cord Neurostimulator 63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed

Spinal Cord Neurostimulator 63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed

Spinal Cord Neurostimulator 63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed

Spinal Cord Neurostimulator 63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed

Spinal Cord Neurostimulator 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling

Spinal Cord Neurostimulator 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receive

Spinal Cord Neurostimulator C1767 Generator, neurostimulator (implantable), non-rechargeable

Spinal Cord Neurostimulator C1778 Lead, neurostimulator (implantable)

Spinal Cord Neurostimulator C1787 Patient programmer, neurostimulator

Spinal Cord Neurostimulator C1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system

Spinal Cord Neurostimulator C1883 Adaptor/extension, pacing lead or neurostimulator lead (implantable) Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Spinal Cord Neurostimulator C1897 Lead, neurostimulator test kit (implantable)

Spinal Cord Neurostimulator L8679 Implantable neurostimulator, pulse generator, any type

Spinal Cord Neurostimulator L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only

Spinal Cord Neurostimulator L8682 Implantable neurostimulator radiofrequency receiver

Spinal Cord Neurostimulator L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver

Spinal Cord Neurostimulator L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension

Spinal Cord Neurostimulator L8686 Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension

Spinal Cord Neurostimulator L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension

Spinal Cord Neurostimulator L8688 Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension

Spinal Cord Neurostimulator L8695 External recharging system for battery (external) for use with implantable neurostimulator, replacement only

Spinal Devices (Facet Implant) 0219T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical

Spinal Devices (Facet Implant) 0220T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic

Spinal Devices (Facet Implant) 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

Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; each additional vertebral Spinal Devices (Facet Implant) 0222T segment

Spinal Fusion for Scoliosis 22800 Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments

Spinal Fusion for Scoliosis 22802 Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments

Spinal Fusion for Scoliosis 22804 Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Spinal Fusion for Scoliosis 22808 Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments

Spinal Fusion for Scoliosis 22810 Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments

Spinal Fusion for Scoliosis 22812 Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral Spinal Fusion- Unspecified 22534 segment (List separately in addition to code for primary procedure)

Spinal Fusion- Unspecified 22585 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace

Spinal Fusion- Unspecified 22614 Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment

Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional Spinal Fusion- Unspecified 22632 interspace

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other Spinal Fusion- Unspecified 22634 than for decompression), single interspace and segment; each additional interspace and segment

Spinal Fusion- Unspecified 22830 Exploration of spinal fusion

Spine Non-Specific 20931 Allograft, structural, for spine surgery only

Spine Non-Specific 20936 Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision

Spine Non-Specific 20937 Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision)

Spine Non-Specific 20938 Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision

Spine Non-Specific 22100 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical

Spine Non-Specific 22101 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracic

Spine Non-Specific 22102 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar

Spine Non-Specific 22103 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; each additional segment Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Spine Non-Specific 22110 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; cervical

Spine Non-Specific 22112 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; thoracic

Spine Non-Specific 22114 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; lumbar

Spine Non-Specific 22116 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; each additional vertebral segment

Spine Non-Specific 22206 Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); thoracic

Spine Non-Specific 22207 Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); lumbar

Spine Non-Specific 22208 Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment

Spine Non-Specific 22210 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical

Spine Non-Specific 22212 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic

Spine Non-Specific 22214 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar

Spine Non-Specific 22216 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment

Spine Non-Specific 22220 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical

Spine Non-Specific 22222 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic

Spine Non-Specific 22224 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar

Spine Non-Specific 22226 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment

Spine Non-Specific 22325 Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; lumbar

Spine Non-Specific 22326 Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; cervical Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Spine Non-Specific 22327 Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; thoracic

Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; each additional fractured vertebra or Spine Non-Specific 22328 dislocated segment

Spine Non-Specific 22818 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments

Spine Non-Specific 22819 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segments

Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet Spine Non-Specific 22840 screw fixation)

Spine Non-Specific 22841 Internal spinal fixation by wiring of spinous processes

Spine Non-Specific 22842 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments

Spine Non-Specific 22843 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments

Spine Non-Specific 22844 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments

Spine Non-Specific 22845 Anterior instrumentation; 2 to 3 vertebral segments

Spine Non-Specific 22846 Anterior instrumentation; 4 to 7 vertebral segments

Spine Non-Specific 22847 Anterior instrumentation; 8 or more vertebral segments

Spine Non-Specific 22848 Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum

Spine Non-Specific 22849 Reinsertion of spinal fixation device

Spine Non-Specific 22850 Removal of posterior nonsegmental instrumentation (eg, Harrington rod)

Spine Non-Specific 22852 Removal of posterior segmental instrumentation

Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to Spine Non-Specific 22853 intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure) Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to Spine Non-Specific 22854 vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure

Spine Non-Specific 22855 Removal of anterior instrumentation

Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, Spine Non-Specific 22859 each contiguous defect (List separately in addition to code for primary procedure)

Spine Non-Specific 22899 Unlisted procedure, spine

Spine Non-Specific 63081 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment

Spine Non-Specific 63082 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment

Spine Non-Specific 63085 Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment

Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, each additional Spine Non-Specific 63086 segment

Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower Spine Non-Specific 63087 thoracic or lumbar; single segment

Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), Spine Non-Specific 63090 lower thoracic, lumbar, or sacral; single segment

Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), Spine Non-Specific 63091 lower thoracic, lumbar, or sacral; each additional segment

Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or Spine Non-Specific 63101 retropulsed bone fragments); thoracic, single segmen

Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or Spine Non-Specific 63102 retropulsed bone fragments); lumbar, single segment

Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or Spine Non-Specific 63103 retropulsed bone fragments); thoracic or lumbar, each additional segment

Spine Non-Specific 63300 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, cervical

Spine Non-Specific 63301 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by transthoracic approach Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Spine Non-Specific 63302 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by thoracolumbar approach

Spine Non-Specific 63304 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, cervical

Spine Non-Specific 63305 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by transthoracic approach

Spine Non-Specific 63306 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by thoracolumbar approach

Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, lumbar or sacral by transperitoneal or Spine Non-Specific 63307 retroperitoneal approach

Spine Non-Specific 63308 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; each additional segment

Thoracic Laminectomy and Discectomy 63055 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic

Thoracic Laminectomy and Discectomy 63064 Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; single segment

Thoracic Laminectomy and Discectomy 63066 Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; each additional segment

Thoracic Laminectomy and Discectomy 63077 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, single interspace

Thoracic Laminectomy and Discectomy 63078 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, each additional interspace

Thoracic Laminectomy and Discectomy 63195 Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 stage; thoracic

Thoracic Laminectomy and Discectomy 63197 Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage; thoracic

Thoracic Laminectomy and Discectomy 63199 Laminectomy with cordotomy with section of both spinothalamic tracts, 2 stages within 14 days; thoracic

Thoracic Laminectomy and Discectomy 63251 Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracic

Thoracic Laminectomy and Discectomy 63271 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; thoracic

Thoracic Laminectomy and Discectomy 63286 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracic Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Thoracic Spinal Fusion 22532 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic

Thoracic Spinal Fusion 22556 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic

Thoracic Spinal Fusion 22610 Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed)

Total Ankle Replacement and Revision 27700 Arthroplasty, ankle

Total Ankle Replacement and Revision 27702 Arthroplasty, ankle; with implant (total ankle)

Total Ankle Replacement and Revision 27703 Arthroplasty, ankle; revision, total ankle

Total Ankle Replacement and Revision 27704 Removal of ankle implant

Total Hip Replacement 27120 Hip Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type)

Total Hip Replacement 27122 Hip Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure)

Total Hip Replacement 27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft

Total Hip Replacement 27132 Hip Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft

Total Knee Replacement 27445 Arthroplasty, knee, hinge prosthesis (eg, Walldius type)

Total Knee Replacement 27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)

Wrist Fusion 25800 ARTHRODESIS WRIST COMPLETE W/O BONE GRAFT

Wrist Fusion 25805 ARTHRODESIS WRIST W/SLIDING GRAFT

Wrist Fusion 25810 ARTHRODESIS WRIST W/ILIAC/OTHER AUTOGRAFT

Wrist Fusion 25820 ARTHRODESIS WRIST LIMITED W/O BONE GRAFT Musculoskeletal Surgical Procedures Requiring Prior Authorization

Procedure Code Description

Wrist Fusion 25825 ARTHRODESIS WRIST LIMITED W/AUTOGRAFT

Wrist Replacement 25332 Arthroplasty, wrist, with or without interposition, with or without external or internal fixation

Wrist Replacement 25441 Arthroplasty with prosthetic replacement; distal radius

Wrist Replacement 25442 Arthroplasty with prosthetic replacement; distal ulna

Wrist Replacement 25443 Arthroplasty with prosthetic replacement; scaphoid carpal (navicular)

Wrist Replacement 25444 Arthroplasty with prosthetic replacement; lunate

Wrist Replacement 25445 Arthroplasty with prosthetic replacement; trapezium

Wrist Replacement 25446 Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist)