Does 0275T require prior authorization?

No, 0275T does not require prior authorization (high confidence). Code is covered without prior authorization.

`0275T` — Removal of bone from lower spine for decompression of nerve tissue using imaging guidance, accessed through the skin

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Imaging report confirming nerve-root compression (e.g., MRI) with correlation to clinical findings.
Clinical documentation of radiculopathy with motor deficit including MRC muscle strength score and ambulatory status.
Documentation of conservative therapy: dates and duration (≥4 weeks physical therapy or prescribed home exercise or documented inability to tolerate; ≥4 weeks activity modification), details of other required conservative interventions, and documentation showing failure to respond within the last year or documentation of worsening weakness.
Clinical documentation of radiculopathy with sensory deficit localized to a nerve root distribution (pain, paresthesias, numbness).

Open discectomy or microdiscectomy for symptomatic lumbar disc herniation where a portion of the intervertebral disc is compressing the nerve root or spinal cord.
Use of microdiscectomy/open discectomy with or without headlight, loupe, or microscope magnification for removal of disc material compressing neural elements.
Member is age ≥ 18 years.
Diagnosis of herniated lumbar disc with nerve root compression confirmed by imaging.
Radiculopathy with motor deficit and severe weakness in a nerve-root distribution (Medical Research Council [MRC] score ≤ 3) or inability to ambulate.
Radiculopathy with mild-to-moderate weakness (MRC = 4) AND either (a) documented worsening weakness/motor deficit, OR (b) failure to respond to conservative therapy within the last year (see conservative therapy requirements).

AMBETTER-CP.MP.114 — Disc Decompression Procedures

BCBSIL-SUR712.035 — Image-Guided Minimally Invasive Decompression for Spinal Stenosis

BCBSMT-SUR712.035 — Image-Guided Minimally Invasive Decompression for Spinal Stenosis

BCBSNM-SUR712.035 — Image-Guided Minimally Invasive Decompression for Spinal Stenosis

BCBSOK-SUR712.035 — Image-Guided Minimally Invasive Decompression for Spinal Stenosis

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