CMM-600: Preface to Spine Surgery Guidelines

Covers elective spine surgery (including fusion and disc arthroplasty) subject to prior authorization and specifically excludes using discography or MR spectroscopy to determine medical necessity; urgent/emergent cases follow 2019 NCQA criteria and may waive some requirements. Key requirements: submit PA ≥2 weeks before elective surgery with CPT/ICD codes, detailed prior non‑surgical treatment history and responses, independent CT/MRI/myelography reports (with reconciled discrepancies), nicotine‑free verification for fusion (blood cotinine ≤10 ng/mL after ≥6 weeks abstinence unless urgent or myelopathy), and documented trial of ESIs/SNRBs when required unless contraindicated (e.g., allergy, altered epidural space, anticoagulation/bleeding disorder, infection, or steroid‑sensitive comorbidities).

"Prior-authorization requests should be submitted at least two weeks prior to the anticipated date of an elective spinal surgery."