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Musculoskeletal Surgical Procedures Requiring Prior Authorization (Effective 11.1.2020)

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Musculoskeletal Surgical Procedures Requiring Prior Authorization (Effective 11.1.2020) Musculoskeletal Surgical Procedures Requiring Prior Authorization (Effective 11.1.2020) 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 In Addition Acromioplasty and Rotator Cuff Repair 29826 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 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 segments; Cervical Laminectomy and Discectomy 63001 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 vertebral Cervical Laminectomy and Discectomy 63015 segments; cervical Cervical Laminectomy and Discectomy 63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single Cervical Laminectomy and Discectomy 63040 interspace; cervical Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single Cervical Laminectomy and Discectomy 63043 interspace; each additional cervical interspace (List separately in addition to code for primary procedure) 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]), single Cervical Laminectomy and Discectomy 63045 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 bone graft Cervical Laminectomy and Discectomy 63051 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 Musculoskeletal Surgical Procedures Requiring Prior Authorization (Effective 11.1.2020) Procedure Code Description 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 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 foraminotomy), Cervical Laminectomy and Discectomy 0274T 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 additional Cervical Spinal Fusion 22552 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 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 Musculoskeletal Surgical Procedures Requiring Prior Authorization (Effective 11.1.2020) Procedure Code Description 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
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