eviCore MSK spine procedures and services requiring prior authorization This list applies to groups using eviCore authorizations for the MSK Spine Surgery program Updated 1/13/2020 *Check EBT to verify member enrollment in eviCore program MSK Spine Surgery Procedures CPT Code Description Allograft, morselized, or placement of osteopromotive material, for spine 20930 surgery only (List separately in addition to code for primary procedure) Allograft, structural, for spine surgery only (List separately in addition to 20931 code for primary procedure) Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 22206 vertebral segment (eg, pedicle/vertebral body subtraction); thoracic Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 22207 vertebral segment (eg, pedicle/vertebral body subtraction); lumbar Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); each 22208 additional vertebral segment (List separately in addition to code for primary procedure) Osteotomy of spine, posterior or posterolateral approach, 1 vertebral 22210 segment; cervical Osteotomy of spine, posterior or posterolateral approach, 1 vertebral 22212 segment; thoracic Osteotomy of spine, posterior or posterolateral approach, 1 vertebral 22214 segment; lumbar Osteotomy of spine, posterior or posterolateral approach, 1 vertebral 22216 segment; each additional vertebral segment (List separately in addition to primary procedure) Osteotomy of spine, including discectomy, anterior approach, single 22220 vertebral segment; cervical Osteotomy of spine, including discectomy, anterior approach, single 22222 vertebral segment; thoracic Osteotomy of spine, including discectomy, anterior approach, single 22224 vertebral segment; lumbar Osteotomy of spine, including discectomy, anterior approach, single 22226 vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure) Updated 1/13/2020 modahealth.com CPT Code Description Percutaneous vertebroplasty (bone biopsy included when performed), 1 22510 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic Percutaneous vertebroplasty (bone biopsy included when performed), 1 22511 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging 22512 guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure) Injection of bone cement into body of middle spine bone accessed 22513 through the skin using imaging guidance Injection of bone cement into body of lower spine bone accessed 22514 through the skin using imaging guidance Injection of bone cement into body of middle or lower spine bone 22515 accessed through the skin using imaging guidance Percutaneous intradiscal electrothermal annuloplasty, unilateral or 22526 bilateral including fluoroscopic guidance; single level Percutaneous intradiscal electrothermal annuloplasty, unilateral or 22527 bilateral including fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure) Arthrodesis, lateral extracavitary technique, including minimal 22532 discectomy to prepare interspace (other than for decompression); thoracic Arthrodesis, lateral extracavitary technique, including minimal 22533 discectomy to prepare interspace (other than for decompression); lumbar Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); 22534 thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure) Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas- 22548 axis), with or without excision of odontoid process Arthrodesis, anterior interbody, including disc space preparation, 22551 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 22552 nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure) Updated 1/13/2020 modahealth.com CPT Code Description Arthrodesis, anterior interbody technique, including minimal discectomy 22554 to prepare interspace (other than for decompression); cervical below C2 Arthrodesis, anterior interbody technique, including minimal discectomy 22556 to prepare interspace (other than for decompression); thoracic Arthrodesis, anterior interbody technique, including minimal discectomy 22558 to prepare interspace (other than for decompression); lumbar 22590 Arthrodesis, posterior technique, craniocervical (occiput-C2) 22595 Arthrodesis, posterior technique, atlas-axis (C1-C2) Arthrodesis, posterior or posterolateral technique, single level; cervical 22600 below C2 segment Arthrodesis, posterior or posterolateral technique, single level; thoracic 22610 (with lateral transverse technique, when performed) Arthrodesis, posterior or posterolateral technique, single level; lumbar 22612 (with lateral transverse technique, when performed) Arthrodesis, posterior or posterolateral technique, single level; each 22614 additional vertebral segment (List separately in addition to code for primary procedure) Arthrodesis, posterior interbody technique, including laminectomy 22630 and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), 22632 single interspace; each additional interspace (List separately in addition to code for primary procedure) Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy 22633 sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single 22634 interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure) Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 22800 vertebral segments Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 22802 vertebral segments Updated 1/13/2020 modahealth.com CPT Code Description Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or 22804 more vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 22808 vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 22810 vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or 22812 more vertebral segments Kyphectomy, circumferential exposure of spine and resection of vertebral 22818 segment(s) (including body and posterior elements); single or 2 segments Kyphectomy, circumferential exposure of spine and resection of vertebral 22819 segment(s) (including body and posterior elements); 3 or more segments 22830 Exploration of spinal fusion Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw 22840 fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure) Internal spinal fixation by wiring of spinous processes (List separately in 22841 addition to code for primary procedure) Posterior segmental instrumentation (eg, pedicle fixation, dual rods with 22842 multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure) Posterior segmental instrumentation (eg, pedicle fixation, dual rods with 22843 multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure) Posterior segmental instrumentation (eg, pedicle fixation, dual rods with 22844 multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure) Anterior instrumentation; 2 to 3 vertebral segments (List separately in 22845 addition to code for primary procedure) Anterior instrumentation; 4 to 7 vertebral segments (List separately in 22846 addition to code for primary procedure) Anterior instrumentation; 8 or more vertebral segments (List separately 22847 in addition to code for primary procedure) Pelvic fixation (attachment of caudal end of instrumentation to pelvic 22848 bony structures) other than sacrum (List separately in addition to code for primary procedure) 22849 Reinsertion of spinal fixation device Updated 1/13/2020 modahealth.com CPT Code Description Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when conjunction with interbody arthrodesis, each interspace 22853 (List performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition