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Accessing Guidelines for Spine Surgery Services

On November 1, 2016, Horizon Blue Cross Blue Shield of New Jersey expanded our collaboration with eviCore healthcare (eviCore) to require Prior Authorization and Medical Necessity Determination (PA/MND) for Spine Surgery services.

We recently announced that the clinical guidelines used by eviCore to make PA/MND decisions for Spine Surgery services provided to members enrolled in Horizon BCBSNJ plans that participate in the Musculoskeletal Program moved to eviCore’s website.

Horizon BCBSNJ also maintains a separate set of medical policies, the guidelines of which pertain to Spine Surgery services provided to members enrolled in plans that DO NOT participate in the Musculoskeletal Program administered by eviCore.

Please review the information below to ensure that you’re reviewing the appropriate set of Spine Surgery guidelines for your Horizon BCBSNJ patient.

  • If your patient is enrolled in a Horizon BCBSNJ plan that PARTICIPATES in the Musculoskeletal Program administered by eviCore1, please review the guidelines you may access at www.evicore.com/HorizonSpineSurgery.

    For information about our Musculoskeletal Program, visit the Spine Surgery tab of HorizonBlue.com/musculoskeletal or call 1-866-241-6603.

    1Members enrolled in all fully insured Horizon BCBSNJ products as well as those Administrative Services Only (ASO) accounts that have elected to participate in the Musculoskeletal Program.

  • If your patient is enrolled in a Horizon BCBSNJ plan that DOES NOT PARTICIPATE in the Musculoskeletal Program administered by eviCore, please review the medical policies listed below within the Horizon BCBSNJ Medical Policy Manual:

    • Artificial Intervertebral Disc: Cervical Spine
    • Artificial Intervertebral Disc: Lumbar Spine
    • Bone Morphogenetic Protein
    • Discectomy
    • Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
    • Laminectomy
    • Lumbar Spinal Fusion
    • Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation
    • Percutaneous Vertebroplasty and Sacroplasty

    If you are seeking PA for procedure codes that are not managed by eviCore, please call Horizon BCBSNJ’s Physician Services at 1-800-624-1110.

Published on: March 3, 2017, 13:19 p.m. ET
Last updated on: April 5, 2021, 17:23 p.m. ET