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Coverage criteria policies

Spine surgical practice - low back pain office visits

These 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

  1. This policy only applies to:
    1. Members 18 years of age and older
    2. Lumbar spine conditions
    3. 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 low back pain surgery conditions except as described in # 3 & 4 below. (See ICD-10-CM Diagnosis codes that require Prior Authorization 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 authorize 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:
    1. Evidence of tumor, infection or fracture;
    2. Cauda equina syndrome;
    3. Sudden, progressive neurologic deterioration evidenced by:
      1. Acute weakness or decreased muscle control of the leg(s);
      2. Loss of bladder or bowel control; or
      3. Foot drop.
    4. Any other documented emergent neurological condition resulting from a lumbar spine condition
  5. Exempt diagnoses include scoliosis 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 Authorization 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.

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.

The following list, although not all-inclusive, is a list of ICD-10-CM diagnosis codes that require prior authorization 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, M48.8X5-M48.8X9

Ankylosing spondylitis

M46.00, M46.05-M46.09

Spinal enthesopathy

M46.1

Sacroiliitis, not elsewhere classified

M47.20, M47.26-M47.28, M47.815-M47.819, M47.896-M47.9

Spondylosis

M48.20, M48.25-M48.27

Kissing spine

M51.26, M51.27

Displacement of lumbar intervertebral disc

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

Discitis, 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

Spinal stenosis, 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, M99.34

Spinal stenosis, other region other than cervical

M54.5

Lumbago

M54.30-M54.42

Sciatica

M51.15-M51.17, M54.15-M54.17

Intervertebral disc disorders with radiculopathy, thoracolumbar & lumbar regions

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 Authorization if submitted by an orthopedic spine surgeon or neurosurgeon consultation visit for specified lumbar spine conditions.

Codes

Description

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 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 vertebral column

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, M86.58, M86.60, M86.68, M86.8X8, M86.8X9, M86.9

Chronic osteomyelitis, other & unspecified sites

M46.20-M46.28

Osteomyelitis of vertebra

M90.80-M90.89

Osteopathy in diseases classified elsewhere

A18.01

Tuberculosis of spine

M48.50XA-M48.58XS, M80.08XA-M80.08XS, M80.88XA-M80.88XS, M84.48XA-M84.48XS, M84.58XA-M84.58XS, M84.68XA-M84.68XS

Pathologic fracture of vertebrae

M40.00-M40.299

Kyphosis

M41.00-M41.9, M96.5

Scoliosis

M40.40-M40.57

Lordosis

M43.8X9

Other specified deforming dorsopathies, site unspecified

Q76.2

Congenital spondylolysis

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, S32.2XXA-S32.2XXB

Fracture of lumbar vertebra, sacrum and coccyx

S33.101A-S33.101S, S33.111A-S33.111S, S33.121A-S33.121S, S33.131A-S33.131S, S33.141A-S33.141S

Closed dislocation, lumbar vertebra

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

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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.

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Policy activity

  • 10/20/2011 - Date of origin
  • 11/16/2017 - Effective date
Review date
  • 01/2018

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