Does C9757 require prior authorization?

No, C9757 does not require prior authorization (high confidence). Code is covered without prior authorization.

Verity

`C9757` — Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and excision of herniated intervertebral disc, and repair of annular defect with implantation of bone anchored annular closure device, including annular defect measurement, alignment and sizing assessment, and image guidance; 1 interspace, lumbar

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Documentation Required

For repeat procedures beyond specified intervals (e.g., beyond 12 months), submission of clinical review documentation justifying continued treatment.
For oncologic, infectious, or complex structural indications: relevant pathology/imaging reports, operative reports, prior treatments, and specialist consultation notes as applicable to demonstrate meeting of selection criteria.
For inclusion in many interbody fusion device studies: failure of conservative care (commonly documented as unresponsive to at least 6 months of conservative care).

For facet joint injections: documentation that member has symptoms suggestive of facet joint syndrome (absence of radiculopathy, pain aggravated by extension/rotation/lateral bending, not typically associated with neurological deficits), provocative testing on physical exam confirming facet mediated pain (pain exacerbated by extension and rotation), imaging studies ruling out other obvious causes (e.g., fracture, tumor, infection, significant extraspinal lesion), pain limits ADLs, pain duration > 3 months, and pain persisted despite ≥ 6 weeks of conservative treatment (systemic meds and/or PT).

For trigger point injections: documentation that conservative treatments (bed rest, exercises, heat/cold, massage, pharmacotherapies including NSAIDs, muscle relaxants, non-narcotic analgesics) were tried and failed; symptoms persisted > 3 months; trigger points identified by palpation; injections are part of a comprehensive pain management program (PT, education, psychosocial support, oral meds where appropriate); recording of number of sets administered and timing (no repeats > every 7 days during diagnostic phase; after diagnosis, typically no more frequent than once every 2 months; repeated treatment beyond 12 months requires review).

Key Coverage Criteria

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).
Microsurgical anterior foraminotomy: proposed for intractable cervical radiculopathy to remove herniated disc or bone spur via anterior approach without fusion (insufficient high-quality evidence).
Open sacroiliac fusion: proposed for SIJ dysfunction/syndrome when other non-operative treatments failed; evidence insufficient to support routine use.

8 Active Policies

AETNA-CPB-0016 — Back Pain - Invasive Procedures

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

BCBSIL-SUR705.045 — Annulus Closure After Discectomy

BCBSMT-SUR705.045 — Annulus Closure After Discectomy

BCBSNM-SUR705.045 — Annulus Closure After Discectomy

BCBSOK-SUR705.045 — Annulus Closure After Discectomy

REGENCE-SUR243 — Annular Closure Devices

SUR705.045 — Annulus Closure After Discectomy

Prior Authorization

Documentation Required

Key Coverage Criteria

8 Active Policies

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