Pain Management Procedure Codes

eviCore conducts Prior Authorization and Medical Necessity Determination (PA/MND) reviews of the procedure codes below as part of our Musculoskeletal Program for Pain Management Services. This listing was last revised on July 21, 2022 and may be subject to change.

00640
01939
01940
01941
01942
01991
01992
20552
20553
22505
27096
61790
61791
62263
62264
62287
62290
62291
62292
62320
62321
62322
62323
62324
62325
62326
62327
64405
64451
64479
64480
64483
64484
64490
64491
64492
64493
64494
64495
64510
64520
64625
64633
64634
64635
64636
72285
72295
77003
0213T
0214T
0215T
0216T
0217T
0218T
0627T
0628T
0629T
0630T
G0259
G0260
M0076
S2348
S9090

Recent/Upcoming Changes

For services to be provided on and after November 7, 2022, eviCore will also perform PA/MND of the services represented by procedure code 62287.
Effective June 6, 2022, as a result of the Surgical and Implantable Device Management Program expansion to include spine-related services, administered by TurningPoint, the following codes are no longer reviewed by eviCore as part of this program: 63650, 63655, 63663, 63664, 63685, 62350, 62351, 62360, 62361 and 62362.
- Submit PA/MND requests to TurningPoint
  Please submit PA/MND requests to TurningPoint for procedure 62350, 62351, 62360, 62361, 62362, 63650, 63655, 63663, 63664, 63685 for services provided June 6, 2022 and after for patients participating in our Surgical and Implantable Device Management Program for Spine Services.
- Submit PA/MND requests to Horizon for SHBP/SEHBP patients
  Please submit PA/MND requests to Horizon via our online Utilization Management Request Tool for codes 62350, 62351, 62360, 62361, 62362, 63650, 63655, 63663, 63664, 63685 for services provided after June 5, 2022 to patients enrolled in State Health Benefits Program (SHBP)/School Employees' Health Benefits Program (SEHBP) plans.
For services to be provided on and after January 1 2022, eviCore will also perform MND of the services represented by procedure codes 01939, 01940, 01941 and 01942.

Notes

Anesthesia services performed in conjunction with musculoskeletal pain management procedures require separate prior authorization and/or Medical Necessity Determination. Claims submitted for anesthesia services related to a pain management procedure will not be paid if there a valid authorization is not on file.
Procedure codes 00640, 22505, 62263, 62264, M0076, S2348 and S9090 may be considered investigational services.

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