62290
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
2.93
Facility
$142.62
Non-Facility
$370.08
Documentation Required
- The policy does not specify particular medical-record documentation (e.g., required test results or clinical notes) that would render these procedures covered; instead, it states they are unproven and not medically necessary.
- General instruction: When deciding coverage, reference the member-specific benefit plan document and any applicable federal or state mandates; in the event of conflict, the member-specific plan governs.
- If this policy is applied to Medicare Advantage in absence of an NCD/LCD, MAO coverage determinations should rely on objective evidence-based rationale and authoritative evidence (Medicare IOM Pub. No. 100-16, Ch. 4, §90.5).
- Coding note/documentation: Functional anesthetic discography should be billed with CPT code 64999 (billing clarification provided).
Key Coverage Criteria
- CPT 62290 (Injection procedure for discography, each level; lumbar) — covered if selection criteria are met [not covered for functional anesthetic discography].
- Lumbar provocative discography medically necessary for evaluation for disc pathology in persons with persistent, severe low back pain (LBP) and abnormal interspaces on magnetic resonance imaging (MRI), where other diagnostic tests have failed to reveal clear confirmation of a suspected disc as the source of pain, and surgical intervention is being considered.
- CPT 72295 (Discography, lumbar, radiological supervision and interpretation) — covered if selection criteria are met [not covered for functional anesthetic discography].
- ICD-10 codes covered if selection criteria are met: M43.06, M43.07, M43.16, M43.17, M46.46, M46.47, M51.86, M51.87, M47.16, M47.17, M47.816, M47.817, M48.061, M48.07, M51.06, M51.07, M51.16, M51.17, M54.16, M54.17, M51.26, M51.27, M51.36, M51.37, M51.46, M51.47, M54.30, M54.42, M54.50, M54.59, M96.1, S33.100+, S33.141+
- Continuous intraoperative neurophysiologic monitoring (IOM) is considered medically necessary when ALL of the following criteria are met: IOM is performed by either a licensed physician trained in clinical neurophysiology (e.g., a neurologist, physiatrist) or a trained technologist who is practicing within the scope of his/her state license /certification as defined by state law or appropriate authorities and is working under the direct supervision of a physician trained in neurophysiology and i [...]
- Continuous intraoperative neurophysiologic monitoring (IOM) is considered medically necessary when ALL of the following criteria are met: IOM is interpreted by a licensed physician trained in clinical neurophysiology, other than the operating surgeon or anesthesiologist, who is either physically in attendance in the operating suite or present by means of a real-time remote mechanism for all electroneurodiagnostic (END) monitoring situations and is immediately available to interpret the recording [...]
7 Active Policies
AMBETTER-CP.MP.115 — Discography
UHC-POL-epiduroscopy-epidural-lysis-adhesions-discography — Epiduroscopy, Epidural Lysis of Adhesions, and Discography
UMR-POL-UMR-epiduroscopy-epidural-lysis-adhesions-discography — Epiduroscopy, Epidural Lysis of Adhesions, and Discography
SUREST-POL-SUREST-epiduroscopy-epidural-lysis-adhesions-discography — Epiduroscopy, Epidural Lysis of Adhesions, and Discography
Related Codes
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