Does 22630 require prior authorization?

Yes, 22630 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for 22630?

Medicare facility rate: $1510.72. Non-facility rate: $1510.72. Work RVU: 21.54.

HCPCS/CPT

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Work RVU

21.54

Facility

$1510.72

Non-Facility

$1510.72

This article provides billing and coding guidelines that complement Local Coverage Determination (LCD) L37848 for Lumbar Spinal Fusion; refer to LCD L37848 for clinical medical necessity criteria.
Medical record must document that the patient met at least one of the lumbar fusion indications prior to surgery.
For elective procedures, record must verify that the qualified surgeon, operating room, and all necessary equipment and hardware were available prior to induction of anesthesia.
When fusing >1 level for instability, the record must show that each fused level is affected by one of the listed instability causes.

Radiographic or clinical evidence of lumbar spinal instability due to congenital deformity, trauma, fracture, chronic degenerative condition, tumor, infection, erosive condition, space-occupying lesion, or iatrogenic causes.
Symptomatic spinal deformity (without instability or neural compression) with functional limitation in daily activities from back pain, nonresponse to ≥1 year of non-operative treatment, and at least one of: sagittal or coronal imbalance ≥5 cm on full-spine radiograph, progression of deformity ≥10 degrees, or scoliotic curvature >30 degrees.
Revision lumbar fusion for pseudarthrosis after prior spine surgery when all are met: initial postoperative period of reduced pain, ≥1 year since prior surgery, clear radiographic evidence of pseudarthrosis, and exhaustion of available conservative treatments.
Symptomatic compression of neural elements from disc pathology requiring disc excision for decompression at the fused level(s).
No explicit "Covered Indications" or "Medically Necessary" indications are provided in this policy document.
Coverage decisions are to be determined by the member specific benefit plan document (see Instructions for Use).

A56396 — Billing and Coding: Lumbar Spinal Fusion

L37848 — Lumbar Spinal Fusion

CARELON-spine-surgery-2024-01-01 — Spine Surgery

UHC-POL-minimally-invasive-spine-surgery — Minimally Invasive Spine Surgery Procedures

UMR-POL-UMR-minimally-invasive-spine-surgery — Minimally Invasive Spine Surgery Procedures

Ask Verity about documentation requirements, denial risks, or coverage in your state.