63285
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
37.10
Facility
$2524.11
Non-Facility
$2524.11
Documentation Required
- Diagnostic imaging studies confirming spinal fractures when that indication is used
- Documentation of objective neurologic signs (e.g., Hoffman sign, hyperreflexia, increased tone or spasticity).
- Please refer to CMS Medicare Coverage Database for the most current applicable CMS National Coverage Determination (NCD)/Local Coverage Determination (LCD)/Local Coverage Article (LCA). Refer to CMS website for the most current applicable CMS Online Manual System (IOMs) and Transmittals.
- Related Humana Medicare Advantage Medical/Pharmacy Coverage Policies: Injections for Chronic Pain Conditions; Interspinous Process Decompression Spacers; Neuroablative Techniques for Chronic Pain; Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty; Spinal Fusion Surgery.
Key Coverage Criteria
- Procedures that may be used to accomplish decompression, including discectomy, corpectomy, facetectomy, foraminectomy, foraminotomy, laminectomy, laminotomy, spinal fusion, or a combination of these procedures.
- Discectomy is the most common surgical treatment for ruptured or herniated discs, particularly of the lumbar spine.
- Percutaneous Image-Guided
- Spinal decompression surgery to relieve symptoms caused by pressure or compression on the spinal cord and/or spinal nerve roots.
- Lumbar spinal stenosis (as indicated by the title and context).
- Large posterior osteophyte adjacent to the end plate
2 Active Policies
CARELON-spine-surgery-2024-01-01 — Spine Surgery
HUMANA-SPINAL-DECOMPRESSION-SURGERY-MA — Spinal Decompression Surgery - Medicare Advantage
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.