0628T — Perq njx algc fluor lmbr ea
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Required documentation for claims is as specified in LCD DL39942 and may include operative reports, imaging, clinical notes of prior conservative management, and applicable coding/billing forms; consult the LCD for exact required elements.
- This billing/coding article complements Local Coverage Determination L39942 for intervertebral disc repair; review LCD L39942 and the full article for specific coverage and coding rules.
- This article contains billing, coding, and guideline information that complements Local Coverage Determination DL39958; specific documentation requirements (e.g., medical records, prior authorizations, or coding guidance) are provided in the referenced LCD rather than in this article.
- No specific billing/coding criteria provided in the supplied text; document references the Local Coverage Determination L39958 for Intervertebral Disc Repair.
Key Coverage Criteria
- Intervertebral disc repair is covered when the procedure and clinical indications meet the requirements specified in Local Coverage Determination DL39942.
- Coverage for intervertebral disc repair is determined by and must align with the Local Coverage Determination DL39962 clinical criteria.
- None — this Medical Policy states the following procedures are unproven and not medically necessary due to insufficient evidence of efficacy: Annular closure devices (ACDs); Percutaneous injection of allogeneic cellular/tissue-based products; Thermal intradiscal procedures (TIPs) for treating discogenic pain. (Coverage Rationale)
- Note (informational, not a payer coverage determination): FDA premarket approval (PMA) for the Barricaid® Annular Closure Device is described in the document: 'indicated for reducing the incidence of reherniation and reoperation in skeletally mature patients with radiculopathy (with or without back pain) attributed to a posterior or posterolateral herniation, and confirmed by history, physical examination and imaging studies which demonstrate neural compression using MRI to treat a large annular [...]
- Intradiscal injection of nucleus pulposus allograft with viable cells for treatment of degenerative disc disease is considered experimental, investigational and/or unproven and has no covered indications.
- Allograft injection for treatment of degenerative disc disease
18 Active Policies
A59865 — Billing and Coding: Intervertebral Disc Repair
A59866 — Billing and Coding: Intervertebral Disc Repair
A59879 — Billing and Coding: Intervertebral Disc Repair
A59880 — Billing and Coding: Intervertebral Disc Repair
A59881 — Billing and Coding: Intervertebral Disc Repair
Related Codes
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