Spine surgical practice - low office visitsThese services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Effective 4/1/2020, the Medical spine consult (MSC) requirement and prior notification requirement for spine surgery office visits is temporarily suspended until further notice.

1. This policy only applies to: A. Members 18 years of age and older B. Lumbar spine conditions C. HealthPartners contracted providers 2. Evaluation at a Designated Medical Spine Center (MSC) by a designated Medical Spine Specialist (MSS) physician is required prior to evaluation and management office visits for surgery conditions except as described in # 3 & 4 below. (See ICD-10-CM Diagnosis codes that require prior notification below). The designated network requirement will be applied to patients residing in regions where patients have access to a medical spine specialist. Patients residing outside of those regions will be exempt from seeing a designated medical spine specialist. Refer to the related content for more information. 3. Orthopedic surgeons and neurosurgeons are required to prior notify all office consultations for lumbar spine conditions unless there is a need for an emergent surgical evaluation (see #4) or care was provided in the emergency department or inpatient setting. 4. Patients with observed, progressive neurologic deterioration from a lumbar spine condition are not required to have an evaluation at a Designated MSC prior to a low back pain evaluation and/or management office visit. This can include any of the following: A. Evidence of tumor, infection or fracture; B. Cauda equina syndrome; C. Sudden, progressive neurologic deterioration evidenced by: i. Acute weakness or decreased muscle control of the leg(s); ii. Loss of bladder or bowel control; or iii. Foot drop. D. Any other documented emergent neurological condition resulting from a lumbar spine condition 5. Exempt diagnoses include and spina bifida. 6. A documented MSC evaluation must be done within six months prior to the surgical consultation visit. 7. The length of the authorization will be up to six (6) months following the original date of the approval. A second prior notification will be required if the initial surgery consult visit is not scheduled within that 6 months. 8. Members are not required to have an evaluation at a Designated Medical Spine Center by the Designated Medical Spine Specialist physician prior to the first and second annual post-op follow-up visit when seen by the original surgeon that performed the surgery.

Definitions

Designated Medical Spine Center - Designated Medical Spine Centers are clinics with medical spine specialists whose focus is on the non-surgical, comprehensive management of spine conditions using a bio-psycho-social active re-conditioning model. A Designated Medical Spine Center has shown a commitment to evidence based practice as demonstrated by use of ICSI guidelines and evidence driven protocols.

Designated Medical Spine Specialist - A medical spine specialist is a physician with a specialty in Physical Medicine and Rehabilitation, Occupational Medicine, Sports Medicine with advanced extensive training in spine care and rehabilitation

Lumbar Spine Conditions - Specified lumbar spine conditions are defined in code ICD-10-CM code set below.

Codes If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.

Page 1 of 4

The following list, although not all-inclusive, is a list of ICD-10-CM diagnosis codes that require prior notification for an orthopedic spine surgery or neurosurgeon consultation visit for specified lumbar spine conditions. Codes Description G89.4 Chronic pain syndrome G54.1 Lumbosacral plexus disorders G54.4 Lumbosacral root disorders, not elsewhere classified G57.00-G57.02 Lesion of sciatic nerve M08.1, M45.0, M45.5-M45.9, Ankylosing M48.8X5-M48.8X9 M46.00, M46.05-M46.09 Spinal enthesopathy M46.1 , not elsewhere classified M47.20, M47.26-M47.28, M47.815-M47.819, M47.896- M47.9 M48.20, M48.25-M48.27 Kissing spine M51.26, M51.27 Displacement of lumbar M51.9 Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder M51.45-M51.47 Schmorl's nodes M51.35-M51.37 Other thoracolumbar and lumbosacral intervertebral disc degeneration M96.1 Postlaminectomy syndrome, unspecified region M46.40, M46.45-M46.49 , unspecified, thoracolumbar, lumbar, lumbosacral, sacrococcygeal and multiple sites M51.86, M51.87 Other intervertebral disc disorders of lumbar & lumbosacral regions M51.36, M51.37 Degeneration of lumbar or lumbosacral intervertebral disc M96.1 Postlaminectomy syndrome, not elsewhere classified M48.00 , site unspecified M48.06, M48.07, Spinal stenosis of lumbar & lumbosacral region M99.22-M99.24 Subluxation stenosis of neural canal of thoracic, lumbar & sacral regions M99.32-M99.34 Osseous stenosis of neural canal of thoracic, lumbar & sacral regions M99.42-M99.44 Connective tissue stenosis of neural canal of thoracic, lumbar & sacral regions M99.52-M99.54 Intervertebral disc stenosis of neural canal of thoracic, lumbar & sacral regions M99.62-M99.64 Osseous and subluxation stenosis of intervertebral foramina of thoracic, lumbar & sacral regions M99.72-M99.74 Connective tissue and disc stenosis of intervertebral foramina of thoracic, lumbar & sacral regions M48.08, M99.24-M99.26, Spinal stenosis, other region other than cervical M99.34 M54.5 Lumbago M54.30-M54.42 M51.15-M51.17, M54.15- Intervertebral disc disorders with , thoracolumbar & lumbar regions M54.17 M54.5, M54.89, M54.9 Low back pain & other and unspecified dorsalgia M43.27, M43.28 Fusion of spine, lumbosacral, sacral & sacrococcygeal regions M53.2X7, M53.2X8 Spinal instabilities, lumbosacral, sacral & sacrococcygeal regions M53.3 Sacrococcygeal disorders, not elsewhere classified M53.86-M53.88 Other specified dorsopathies, lumbar, lumbosacral, sacral & sacrococcygeal regions M62.830 Muscle spasm of back M43.20, M43.25-M43.28 Fusion of spine M43.8X9 Other specified deforming dorsopathies, site unspecified M53.80, M53.9 Other specified and unspecified dorsopathies

The following list, although not all inclusive, is a list of E&M codes that require prior notification if submitted by an orthopedic spine surgeon or neurosurgeon consultation visit for specified lumbar spine conditions. Code Description s 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the

Page 2 of 4

patient and/or family 99202 Office or other outpatient visit….new patient….expanded problem….20 minutes 99203 Office or other outpatient visit….new patient….30 minutes 99204 Office or other outpatient visit….new patient….comprehensive….45 minutes 99205 Office or other outpatient visit….comprehensive….high complexity…. 60 minutes 99212 Office or other outpatient visit….established patient….problem focused....10 minutes 99213 Office or other outpatient visit….established patient….expanded….15 minutes 99214 Office or other outpatient visit….established patient….detailed….25 minutes 99215 Office or other outpatient visit….established patient….comprehensive…. 40 minutes

The following diagnosis codes (although not all-inclusive) are exempt from the requirement for a documented Medical Spine Center Evaluation before orthopedic spine surgeon or neurosurgeon surgical consultation office visits. ICD-10-CM Codes Description C41.2 Malignant neoplasm of C72.0, C72.1 Malignant neoplasm of spinal cord & cauda equina D16.6 Benign neoplasm of vertebral column D33.4 Benign neoplasm of spinal cord D43.0-D43.2, D43.4 Neoplasm of uncertain behavior of brain and spinal cord G95.11, G95.19 Vascular myelopathies G99.2 Myelopathy in other diseases classified elsewhere G95.20, G95.9 Other & unspecified diseases of spinal cord G83.4 Cauda equina syndrome N31.0, N31.1 Neuropathic bladder, not elsewhere classified N31.9 Neuromuscular dysfunction of bladder, unspecified M47.16 Other spondylosis with myelopathy, lumbar region M48.30-M48.38 Traumatic spondylopathy M47.10 Other spondylosis with myelopathy, site unspecified M51.9 Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder M51.06 Intervertebral disc disorders with myelopathy, lumbar region M86.00, M86.08 M86.10, M86.18, M86.20, M86.28 Acute osteomyelitis, other & unspecified sites M86.30, M86.38, M86.40, M86.48, M86.50, Chronic osteomyelitis, other & unspecified sites M86.58, M86.60, M86.68, M86.8X8, M86.8X9, M86.9 M46.20-M46.28 Osteomyelitis of M90.80-M90.89 Osteopathy in diseases classified elsewhere A18.01 Tuberculosis of spine M48.50XA-M48.58XS, M80.08XA-M80.08XS, Pathologic fracture of vertebrae M80.88XA-M80.88XS, M84.48XA-M84.48XS, M84.58XA-M84.58XS, M84.68XA-M84.68XS M40.00-M40.299 M41.00-M41.9, M96.5 Scoliosis M40.40-M40.57 M43.8X9 Other specified deforming dorsopathies, site unspecified Q76.2 Congenital S12.000A-S12.691B, S12.9XXS-S12.9XXD Fracture of cervical vertebra and other parts of neck S22.000A-S22.089B Fracture of thoracic vertebra S32.000A-S32.059B, S32.10XA-S32.19XB, Fracture of lumbar vertebra, sacrum and coccyx S32.2XXA-S32.2XXB S33.101A-S33.101S, S33.111A-S33.111S, Closed dislocation, lumbar vertebra S33.121A-S33.121S, S33.131A-S33.131S, S33.141A-S33.141S S34.01XA-S34.01XS, S34.101A-S34.129S Lumbar spinal cord injury without spinal bone injury S34.3XXA-S34.3XXS Cauda equina spinal cord injury without spinal bone injury T84.60XA-T84.7XXS Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft Q05.0-Q05.9 Spina bifida CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association

Page 3 of 4

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Approved Medical Director Committee 10/20/11; Effective 1/1/12; Revised 11/13/17 Annual review 10/2012, 1/15/13, 1/2014, 1/2015, 1/2016, 1/2017, 1/2018, 12/2018, 12/2019, 12/2020

Page 4 of 4