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Spine Surgery services to require PA/MND

Beginning November 1, 2016, Horizon Blue Cross Blue Shield of New Jersey will expand our collaboration with eviCore healthcare (f/k/a CareCore National) to require Prior Authorization & Medical Necessity Determination (PA/MND) for Spine Surgery services. This collaboration will be known as Horizon BCBSNJ's Musculoskeletal Program. In addition to certain spine surgery services, this program will include those services that are part of our current Pain Management Program managed by eviCore.

PA/MND of these services will provide improved quality of care and outcomes through better coordination of care among Horizon BCBSNJ, the patients and their physician care teams from diagnosis through treatment and recovery. Spine Surgery services will be reviewed by eviCore pre- or post-service to:

  • Determine medical necessity;
  • Ensure the surgery is performed at the appropriate site of service; and
  • Ensure appropriate conservative therapies are attempted prior to invasive procedures.

Please obtain PA/MND for Horizon BCBSNJ patients who may need Spine Surgery services prior to delivery of the services to ensure that coverage will be provided. At the same time, eviCore will also review and approve for coverage the site of service for surgery (inpatient and outpatient). Services deemed not medically necessary when reviewed on a post-service basis will not be covered or paid for by Horizon BCBSNJ.

Please note: If an out-of-network co-surgeon will be participating in the spine surgery, it is the referring/rendering health care professional’s responsibility to inform the patient that the patient may be responsible for the higher out-of-pocket costs associated with using a nonparticipating co-surgeon.

Spine Surgery Services that require PA/MND
Review the list of the Spine Surgery procedure codes that are part of this program.

How to obtain PA/MND for Spine Surgery services
To obtain PA/MND from eviCore, please:

  • Submit a request online through
  • Or call 1-866-241-6603, between 7 a.m. and 7 p.m., Eastern Time.

You must provide eviCore with:

  • The member’s
    • ID number
    • First and last names
    • Date of birth
  • The rendering, referring or ordering physician’s
    • First and last names
    • National Provider Identifier (NPI)
    • Tax Identification Number (TIN)
    • Fax number
  • The rendering facility’s
    • Name
    • NPI
    • TIN
    • Street address
    • Fax number
  • CPT® codes and diagnosis codes
  • Place of service
  • All relevant clinical notes, imaging/X-ray reports and any anticipated implant, technology or hardware to be used

Review Medical Policy Information
We encourage you to visit our online Medical Policy Manual to review the following revised Horizon BCBSNJ Medical Policies that will be effective and applied as of November 1, 2016. These Medical Policies provide the clinical criteria used by eviCore in making PA/MND determinations with regard to the spine surgery services within the Musculoskeletal Program:

  • Cervical Fusion (Arthrodesis)
  • Cervical Decompression
  • Lumbar Decompression
  • Cervical Microdiscectomy
  • Lumbar Microdiscectomy
  • Electrical Bone Growth Stimulation of the Spine
  • Bone Graft Substitute
  • Cervical Total Disc Arthroplasty
  • Lumbar Total Disc Arthroplasty
  • Lumbar Fusion (Arthrodesis)
  • Vertebral Augmentation (Percutaneous Vertebroplasty/Kyphoplasty)

Horizon BCBSNJ values your participation in our network. If you have any questions, please call 1-866-241-6603.

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

Published on: August 1, 2016, 09:00 a.m. ET
Last updated on: November 25, 2020, 00:30 a.m. ET