Payer PolicyActive
Addendum to the eviCore Musculoskeletal Advanced Procedures Guidelines
EVICORE-MSK_ADVANCED-89327ADF
EviCore by Evernorth
Effective: February 4, 2021
Updated: January 13, 2026
created · Dec 5, 2025
Policy Summary
The addendum (code changes effective 01/01/2021) adds CPT 0627T–0630T (percutaneous allogeneic cellular/tissue intervertebral disc injections, lumbar) to the eviCore list of “Codes Considered Experimental, Investigational or Unproven” (therefore not supported) and removes CPT 0228T–0231T (ultrasound‑guided transforaminal epidural injections, cervical/thoracic/lumbar/sacral) from that experimental list. No covered indications, clinical limitations, documentation requirements, or other authorization criteria are specified in this addendum.
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