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Magellan Matrix 2021

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Magellan Matrix 2021 Utilization Review Matrix 2021 MVP Health Care Musculoskeletal Surgery (Spine) LUMBAR SPINE SURGERY Primary Primary Surgery Primary Surgery Additional Covered Other Procedure CPT Allowable Billed Ancillary Procedures/Codes Request Procedures/Codes Names Code Groupings 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 understood There are multiple CPT codes that can be associated with each procedure. These are to be included in conjunction and do not assumed to be part of the primary surgery request and when completed in combination, require precertification from the health do not require a separate authorization. plan. *Please note: This is not an all-inclusive list of every ancillary code. 62380, 63030, Lumbar 63030 +63035 Discectomy Microdiscectomy 63005, 63012, 63017, 63042, Laminectomy, Lumbar +63044, 63047, Microdiscectomy: 62380, 63047 Laminotomy, Decompression +63048, 63056, 63030, +63035 Foraminotomy +63057 Microdiscectomy: 62380, Instrumentation: +22840, +22841, 63030, +63035 +22842, +22845, +22853 ALIF, TLIF, PLIF, 22533, 22558, Lumbar Fusion - XLIF, OLIF, 22612 22612, 22630, Decompression: 63005, Single Level Bone Grafts : +20930, +20931, Postero-lateral 22633 63012, 63017, 63042, +20936, +20937, +20938 fusion +63044, 63047, +63048, 63056, +63057 Bone Marrow Aspiration: 20939 Microdiscectomy: 62380, 63030, +63035 Instrumentation : +22840, +22841, +22842, +22845, +22853 Decompression: 63005, ALIF, TLIF, PLIF, +22534, +22585, Lumbar Fusion - 63012, 63017, 63042, XLIF, OLIF, 22614 +22614, +22632, Bone Grafts : +20930, +20931, Multiple Levels +63044, 63047, +63048, Postero-lateral +22634 +20936, +20937, +20938 63056, +63057 fusion Bone Marrow Aspiration: 20939 Single Level Fusion: 22533, 22558, 22612, 22630, 22633 CERVICAL SPINE SURGERY Primary Primary Surgery Other Primary Surgery Additional Covered CPT Allowable Billed Ancillary Procedures/Codes Procedure Request Procedures/Codes Code Groupings Names 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. These are understood to be included in assumed to be part of the primary surgery request and when completed in combination, do conjunction and do not require not require a separate authorization. precertification from the health plan. *Please note: This is not an all- inclusive list of every ancillary code. Cervical Anterior Vertebral Corpectomy: Decompression 63075 63075, +63076 63081, +63082, 63300, 63304, Instrumentation : +22859 (without fusion) +63308 Vertebral Corpectomy: 63081, +63082, 63300, 63304, +63308 Instrumentation: +22845, 22853, Anterior Cervical 22548, 22551, 22854 Decompression with 22551 22554 Decompression: 63075, ACDF Fusion - Single Level +63076 Bone Grafts : +20930, +20931, +20936, +20937, +20938 Removal of Artificial Disc: 22864 Vertebral Corpectomy: 63081, +63082, 63300, 63304, +63308 Instrumentation: +22845, +22846, Anterior Cervical Decompression: 63075, 22853, 22854 Decompression with +22552, +22585 +63076 22552 ACDF Fusion - Multiple Bone Grafts : 20930, +20931, Levels Single-Level ACDF: 22548, +20936, +20937, +20938 22551, 22554 Removal of Artificial Disc: Bone Marrow Aspiration: 20939 22864 63001, 63015, Cervical Posterior 63020, +63035, Lamino- Decompression 63045 63040, +63043, foraminotomy, (without fusion) 63045, +63048, Laminectomy 63050, 63051 Cervical Posterior Decompression: 63001, Instrumentation: +22840, +22841 22590, 22595, Decompression with 63015, 63020, +63035, 63040, Posterior fusion, 22600 22600 Fusion - +63043, 63045, +63048, Bone Grafts: +20930, +20931, Arthrodesis Single Level 63050, 63051 +20936, +20937 Decompression: 63001, 63015, 63020, +63035, 63040, Instrumentation: +22840, +22841, Cervical Posterior +63043, 63045, +63048, +22842, +22843, +22844 Decompression with +22595, +22614 Posterior fusion, 22595 63050, 63051 Fusion - Arthrodesis Bone Grafts: +20930, +20931, Multiple Levels Single-Level Fusion: 22590, +20936, +20937 22595, 22600 Instrumentation: 22845, 22853 Disc Removal of Artificial Disc: Cervical Artificial replacement, 22856 22856, 22861 22864 Disc - Single Level Bone Grafts : +20930, +20931, Disc arthroplasty, +20936, +20937, +20938 CADR Single-Level Artificial Disc: Instrumentation: 22845, 22853 22856, 22861 Disc Cervical Artificial +22858, +0098T, replacement, 22858 Bone Grafts : +20930, +20931, Disc - Two Levels 1 +0095T Removal of Artificial Disc: Disc arthroplasty, +20936, +20937, +20938 22864 CADR Payment for procedures is contingent on the patient’s eligibility and plan limitations, if any, at the time the service is delivered. Musculoskeletal surgery services rendered through the Emergency Department are not managed by NIA/Magellan NIA/Magellan does not prior authorize or manage the facility precertification for musculoskeletal surgery services Add-on codes (+) do not require separate authorization and are to be used in conjunction with approved primary code for the service rendered. o Exception: multiple level add-on codes require an authorization for multiple level procedures 1 CPT codes for procedures performed with Cervical Artificial Disc Replacement - are not a covered service and are not reimbursable +0095T, +0098T. Utilization Review Matrix 2021 MVP Health Care Musculoskeletal Surgery (Hip, Knee and Shoulder) HIP SURGERY Primary Primary Surgery Additional Covered Primary Surgery Request CPT Allowable Billed Other Procedure Names Procedures/Codes Code Groupings 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. Revision hip replacement, Revision Revision/Conversion Hip 27134 27132, 27134, 27137, 27138 THA, Revision THR, “Re-do” hip Arthroplasty replacement Total Hip 27130 27130, S2118 Total hip replacement, THA, THR Arthroplasty/Resurfacing 1 Loose Body Removal: 29861 Femoroacetabular Labral repair, Cartilage repair, CAM Impingement (FAI) 29914 29914, 29915, 29916 Chondroplasty: 29862 lesion, Pincer lesion, Acetabuloplasty, Hip Surgery Femoroplasty Synovectomy: 29863 Diagnostic arthroscopy, Synovectomy, Hip Surgery – Other 29863 29860, 29861, 29862, 29863 Loose body removal, Debridement, Chondroplasty, Hip scope KNEE SURGERY Primary Primary Surgery Additional Covered Primary Surgery Request CPT Allowable Billed Other Procedure Names Procedures/Codes Code Groupings 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. Revision knee replacement, Revision Revision Knee Arthroplasty 27487 27486, 27487 TKA, Revision TKR, “Re-do” knee replacement Total Knee Arthroplasty 27447 27447 Total knee replacement, TKA, TKR (TKA) Partial-Unicompartmental Partial knee replacement, Unicondylar 27446 27446, 27438 Knee Arthroplasty (UKA) knee replacement Knee Manipulation under 27570 27570, 29884 Lysis of adhesions, Scar tissue removal Anesthesia (MUA) Meniscectomy: 27332, 27333, 27403, 29868, 29880, 29881, 29882, 29883 Autologous chondrocyte implantation: 27412 Osteochondral Allograft/Autograft: 27415, 27416, 29866, 29867 Anterior cruciate ligament (ACL), Anterior tibial tubercleplasty: 27418 Posterior cruciate ligament (PCL), 27405, 27407, 27409, Knee Ligament Medial collateral ligament (MCL), 29888 27427, 27428, 27429, Reconstruction/Repair Reconstruction of Dislocating Patella: Lateral collateral ligament (LCL), Medial 29888, 29889 27420, 27422, 27424 Patellofemoral Ligament (MPFL), Dislocating patella Lateral Release: 27425, 29873 Chondroplasty : 29877 Microfracture : 29879 Knee 29880 27332, 27333, 27403, Autologous chondrocyte implantation: Meniscectomy/Meniscal 29868, 29880, 29881, 27412 Repair/Meniscal Transplant 29882, 29883 Osteochondral Allograft/Autograft: 27415, 27416, 29866, 29867 Anterior tibial tubercleplasty: 27418 Reconstruction of Dislocating Patella: 27420, 27422, 27424 Lateral Release: 27425, 29873 Loose Body Removal: 29874 Synovectomy : 29875, 29876 Chondroplasty : 29877 Microfracture : 29879 G0289 Diagnostic arthroscopy, Autologous 27412, 27415, 27416, chondrocyte implantation, 27418, 27420, 27422, Osteochondral Allograft/Autograft, 27424, 27425, 29866, Anterior tibial tubercleplasty, Knee Surgery – Other 29879 29867, 29870, 29873, Reconstruction of Dislocating Patella, 29874, 29875, 29876, Lateral Release, Loose Body Removal, 29877, 29879, G0289 Synovectomy, Chondroplasty, Microfracture SHOU LDER SURGERY Primary Primary Surgery Additional Covered Primary Surgery Request CPT Allowable Billed Other Procedure Names Procedures/Codes Code Groupings 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. Revision shoulder replacement, Revision Shoulder 23474 23473, 23474 Revision TSA, Revision TSR, “Re-do” Arthroplasty shoulder replacement Total/Reverse Shoulder 23472 23472 Total shoulder replacement, TSA, TSR Arthroplasty or Resurfacing Partial
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