62287
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
9.03
Facility
$533.75
Non-Facility
$533.75
Documentation Required
- No explicit documentation requirements (e.g., required medical records, test results, or specific clinical notes) are specified in this policy.
- From Instructions for Use: "When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs. Before using this policy, please check the member specific benefit plan document and any applicable federal or state mandates."
- From Instructions for Use: "This Medical Policy may also be applied to Medicare Advantage plans in certain instances. In the absence of a Medicare National Coverage Determination (NCD), Local Coverage Determination (LCD), or other Medicare coverage guidance, CMS allows a Medicare Advantage Organization (MAO) to create its own coverage determinations, using objective evidence-based rationale relying on authoritative evidence (Medicare IOM Pub. No. 100-16, Ch. 4, §90.5)."
Key Coverage Criteria
- 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).
- Epiduroscopy / epidural lysis of adhesions: proposed for diagnosis/treatment of intractable LBP (including failed back surgery syndrome) by visualizing and lysing adhesions and injecting medications (insufficient high-quality evidence to support routine clinical use).
- Kyphoplasty (balloon-assisted vertebroplasty): restore bone height for painful osteoporotic compression fractures (OVCFs); NICE and other assessments note kyphoplasty may be a reasonable alternative to vertebroplasty for recent fractures.
- Sacropasty: injection of PMMA into sacrum for sacral insufficiency fractures (SIFs) in osteoporotic patients to stabilize fracture and relieve pain (developing indication).
- Vesselplasty: image-guided procedure using a containment device and PMMA to treat symptomatic vertebral compression fractures to reduce cement leakage (investigational/promise shown but limited evidence).
15 Active Policies
AMBETTER-CP.MP.114 — Disc Decompression Procedures
AETNA-CPB-0602 — Intradiscal Procedures
UHC-POL-minimally-invasive-spine-surgery — Minimally Invasive Spine Surgery Procedures
UMR-POL-UMR-minimally-invasive-spine-surgery — Minimally Invasive Spine Surgery Procedures
SUREST-POL-SUREST-minimally-invasive-spine-surgery
Related Codes
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