Medical Policy Update - Artificial Intervertebral Disc: Lumbar Spine

Effective August 27, 2018, claims for certain services provided to patients enrolled in Horizon Blue Cross Blue Shield of New Jersey Medicare Advantage (MA) plans will also be processed according to our medical policy, Artificial Intervertebral Disc: Lumbar Spine.

Our medical policy, Artificial Intervertebral Disc: Lumbar Spine, has been updated to include reference to the National Coverage Determination (NCD) and the Local Coverage Determination (LCD) noted below. Horizon BCBSNJ will follow these NCDs/LCDs and Centers for Medicare & Medicaid Services (CMS) guidance in our processing of claims for services provided to Horizon BCBSNJ MA members.

• NCD 150.10: Lumbar Artificial Disc Replacement (LADR)
• LCD L35094: Services That Are Not Reasonable and Necessary

We encourage you to access our Medical Policy Manual to review our medical policy, Artificial Intervertebral Disc: Lumbar Spine.

Claims submitted for services provided on and after August 27, 2018 to members enrolled in Horizon BCBSNJ MA plans will be processed as noted below.

• CPT® codes 22857, 22865, 22862, +0163T, +0164T and/or +0165T will be denied as an experimental/investigational services regardless of the submitted diagnosis code(s).

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims on and after August 27, 2018.

CPT® is a registered mark of the American Medical Association.