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Spine Surgery Procedure Codes

eviCore conducts Prior Authorization and Medical Necessity Determination (PA/MND) reviews of the procedure codes listed below as part of our Musculoskeletal Program for Spine Surgery Services. This listing was last revised on November 29, 2021 and may be subject to change.

Musculoskeletal Program for Spine Surgery to be sunset
Effective June 6, 2022, as a result of the Surgical and Implantable Device Management Program expansion to include spine-related services, administered by TurningPoint, Horizon will sunset the spine-related services part of our Musculoskeletal Program, managed by eviCore healthcare.

  • eviCore will not perform PA/MND reviews of spine-related services that are to be rendered on or after June 6, 2022.
  • eviCore will continue to perform PA/MND reviews of Pain Management services as part of the Musculoskeletal Program.

  • 0274T
  • 0275T
  • 20930
  • 20931
  • 20936
  • 20937
  • 20938
  • 20975
  • 22010
  • 22015
  • 22100
  • 22101
  • 22102
  • 22103
  • 22110
  • 22112
  • 22114
  • 22116
  • 22206
  • 22207
  • 22208
  • 22210
  • 22212
  • 22214
  • 22216
  • 22220
  • 22222
  • 22224
  • 22226
  • 22510
  • 22511
  • 22512
  • 22513
  • 22514
  • 22515
  • 22532
  • 22533
  • 22534
  • 22548
  • 22551
  • 22552
  • 22554
  • 22556
  • 22558
  • 22585
  • 22590
  • 22595
  • 22600
  • 22610
  • 22612
  • 22614
  • 22630
  • 22632
  • 22633
  • 22634
  • 22800
  • 22802
  • 22804
  • 22808
  • 22810
  • 22812
  • 22818
  • 22819
  • 22830
  • 22840
  • 22841
  • 22842
  • 22843
  • 22844
  • 22845
  • 22846
  • 22847
  • 22848
  • 22849
  • 22850
  • 22852
  • 22853
  • 22854
  • 22855
  • 22856
  • 22857
  • 22858
  • 22859
  • 22861
  • 22862
  • 22864
  • 22865
  • 22867
  • 22868
  • 22869
  • 22870
  • 62287
  • 62380
  • 63001
  • 63003
  • 63005
  • 63011
  • 63012
  • 63015
  • 63016
  • 63017
  • 63020
  • 63030
  • 63035
  • 63040
  • 63042
  • 63043
  • 63044
  • 63045
  • 63046
  • 63047
  • 63048
  • 63050
  • 63051
  • 63055
  • 63056
  • 63057
  • 63064
  • 63066
  • 63075
  • 63076
  • 63077
  • 63078
  • 63081
  • 63082
  • 63085
  • 63086
  • 63087
  • 63088
  • 63090
  • 63091
  • 63101
  • 63102
  • 63103
  • 63170
  • 63172
  • 63173
  • 63185
  • 63190
  • 63191
  • 63200
  • 63250
  • 63251
  • 63252
  • 63265
  • 63266
  • 63267
  • 63268
  • 63270
  • 63271
  • 63272
  • 63273
  • 63275
  • 63276
  • 63277
  • 63278
  • 63280
  • 63281
  • 63282
  • 63283
  • 63285
  • 63286
  • 63287
  • 63290
  • 63295
  • 63300
  • 63301
  • 63302
  • 63303
  • 63304
  • 63305
  • 63306
  • 63307
  • 63308
  • C9757

Notes

  • The services represented by procedure codes 0274T, 0275T, 22867, 22868, 22869, 22870, 62287 and 62380 are experimental & investigational..
  • eviCore’s PA/MND will be the based on the primary procedure for the devices represented by procedure codes 22853, 22854 and 22859.

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