Authorization Standards

Authorization Standards for Surgery, Including Cosmetic and Reconstructive Surgery

Investigative: A health service/procedure that has progressed to limited human application and trial, lacks wide recognition as a proven and effective procedure in clinical medicine as determined by InterQual™ or other nationally recognized medical or health organizations, and used by PrimeWest Health in the administration of its program using the following criteria:

  1. The technology must have final approval from the appropriate government regulatory bodies
  2. The scientific evidence must permit conclusions concerning the effectiveness of the technology on health outcomes. Evidence should consist of well-designed and well conducted investigations published in peer review journals. The quality of the body of studies and the consistency of the results are considered in evaluating the evidence.
  3. The technology must improve the net health outcome
  4. The technology must be as beneficial as any established alternatives
  5. Improvement must be attainable outside the investigational settings
  6. A drug or device that the FDA has not yet declared safe and effective for the use prescribed. For purposes of this definition, drugs and devices are those identified in the Food, Drug, and Cosmetic Act.

These criteria determine whether medical devices or treatments are investigational or not. PrimeWest Health then determines coverage based on contract language and medical necessity.

A health service, procedure, or treatment that is concluded to be experimental or investigational in nature is excluded from coverage.

PrimeWest Health uses nationally recognized criteria to determine medical necessity. It is the responsibility of the provider requesting authorization to submit sufficient documentation to establish that coverage standards have been met. Certain situations may require a unique piece of information that will help Utilization Review staff make their decision. Since it is impossible to identify all of the diverse information necessary for each case, PrimeWest Health will make a request will be made for additional information as the situation requires.

Authorization Policy

Authorization is required for all investigative procedures and procedures that may be considered cosmetic. The authorization request originates with the surgeon and must be submitted to PrimeWest Health.

Authorizations are reviewed on a case-by-case basis. Certain situations may require a unique piece of information that will aid the medical review agent in the decision-making process. Since it is impossible to identify all of the diverse information necessary for each case, a request will be made for additional information as the situation requires.

It is the responsibility of the provider requesting authorization to submit sufficient documentation to establish that coverage standards have been met. A provider may choose to submit a summary letter, addressing each element of the standard and current information, in lieu of submitting reports from diagnostic and specialized services noted in the following standards.

If staged plastic and reconstructive surgery is being proposed for correction of a congenital anomaly, the complete plan for future surgeries must be submitted with the first authorization.

The procedure will be authorized, when in the opinion of the medical review agent, all of the following standards are documented:

  1. Medical and psychiatric contraindications to the surgery have been ruled out
  2. The timing for the procedure has been assessed and found to be medically appropriate for the particular condition, age, and stage of development of the individual
  3. Appropriate treatment that is non-surgical, less intrusive, or less expensive has been tried and was not successful, was contraindicated, not applicable, or not available for the given condition
  4. An assessment has been made to determine that the surgical procedure will cause significant improvement of the condition
  5. The member, parent, or guardian fully understands the surgical procedure, the risks involved, and the possible side effects of the surgery
  6. If the reconstruction procedure requires the insertion of an implant, the implant must be FDA-approved
  7. Information submitted is sufficient to establish that the standards listed above have been met. This information must include all of the following:
    1. A statement indicating medical necessity is based on significant medical problems, functional impairment, or is a jeopardy to physical or mental health
    2. Specific diagnosis, date of onset, symptoms, severity, duration, treatment results, and effects on the performance of activities of daily living
    3. When jeopardy to mental health is claimed, an evaluation by a psychologist or a psychiatrist, and a Minnesota Multiphasic Personality Inventory (MMPI) and interpretation are also required
    4. A summary of past clinical history that relates to the current condition including previous procedures, if any, to correct the condition (include surgical reports)
    5. A description of the proposed procedure and the expected results
    6. Specific and exact surgical site including right, left, upper, lower, unilateral, or bilateral (if bilateral, bill two line items with the modifier reported on the second line item), as appropriate
    7. Specify primary and secondary procedures, if applicable
    8. Photographs for situations that are difficult to describe must be submitted. Several different views of the affected part are helpful (photographs should be limited to the affected part)
    9. Additional information requested by the PrimeWest Health medical review agent

As indicated above, all procedures or surgeries that are cosmetic, investigative, or experimental are not covered. A Service Authorization request is needed from the provider, and, if PrimeWest Health determines that the surgery is not cosmetic, is not investigative, and/or is not experimental and it meets the medical necessity of the member and standards of practice, an authorization may be granted.

In addition to the category listed above and to the specific procedures listed under authorization standards:

  1. All implants require Service Authorization (electric stimulator, epidural, intrathecal, neurostimulator, cochlear, artificial cornea, pillar palatal, etc.)
  2. All surgeries for sleep apnea (laser-assisted uvulopalatoplasty [LAUP], uvulopalatopharyngoplasty [UPPP], Uvelectomy, Pillar Palatal implant, tongue base suspension, etc.) require a Service Authorization
  3. All temporomandibular disorder (TMD) surgery and all temporomandibular joint disorder (TMD) treatments require a Service Authorization
  4. All surgeries for weight loss and gastric neurostimulator implants require a Service Authorization

The following are some of the authorization standards and specific documentation needed. This is not an all-inclusive list of all surgeries and procedures that require Service Authorization.

Implantable Neurostimulators

Surgery CPT code 64568 requires service authorization for the insertion of a cranial nerve neurostimulator electrode and generator. Claims for the devices will not pay unless there is an approved Service Authorization for the surgical procedure.

Devices

  • L8680: Implantable neurostimulator, electrode, each
  • L8686: Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension

The following CPT codes for surgeries for the revisions and removals of neurostimulators require Service Authorization:

  • 63688 – Revision or removal of implanted spinal neurostimulator pulse generator or receiver
  • 64569 – Revision or replacement of cranial nerve (e.g., vagus nerve) neurostimulator electrode array, including connection to existing pulse generator
  • 64585 – Revision or removal of peripheral neurostimulator electrode array
  • 64595 – Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver

Authorization Standards for Insertion of Penile Prosthesis

Implantation of a penile prosthesis requires authorization from PrimeWest Health. It is the responsibility of the surgeon to submit the authorization request with all the following information:

  1. Medical history: history of penile dysfunction and report of physical examination
  2. Results of related diagnosis, laboratory tests, and X-rays
  3. Past treatments and results for erectile dysfunction (include pharmacotherapy, devices, etc.)
  4. Summary of evaluation of suitability for implant

Authorization to implant a penile prosthesis for urinary drainage will be approved when, in the opinion of PrimeWest Health, all the following standards have been met:

  1. Other less invasive methods of urine drainage and collection have proven to be inadequate
  2. Information submitted is sufficient to determine the standard is met. The information must include all the following:
    1. Medical history and report of physical exam
    2. Reports of related laboratory tests and X-rays
    3. Summary of approaches to the problems of urinary drainage, with dates indicating periods of time used and when problems began

Authorization Standards for Bariatric Surgery

Adult Bariatric Surgery

Adult bariatric surgery requires a prior authorization.

Adolescent Bariatric Surgery

Adolescent bariatric surgery for members ages 13 – 17 requires a prior authorization.

Required Written Documentation for Bariatric Surgery

  1. Member’s height, weight, and BMI with duration.
  2. All comorbid conditions listed and described.
  3. A detailed statement of the member’s past medically supervised weight loss attempt(s) lasting six months or more (including the duration of each attempt).
  4. The member’s current eating habits.
  5. A list of applicable medical and/or psychiatric contraindications.
  6. Indication of exclusion of any endocrinopathy, peptic ulcer disease (PUD), etc.
  7. A copy of the current psychiatric/psychological assessment as described above.
  8. A drug/alcohol screening.
  9. A copy of the dietary assessment.
  10. A statement detailing the member’s:
    1. Commitment to lose weight
    2. Expectations of the surgical outcome
    3. Willingness to make permanent lifestyle changes
  11. A statement detailing the member’s (if adolescent, at least one custodial parent or guardian’s):
    1. Commitment to support and facility the member’s loss of weight
    2. Expectations of the surgical outcome
    3. Willingness to support and facilitate member’s permanent lifestyle changes
  12. A description of the post-surgical follow-up program, which, if adolescent, must be part of a multidisciplinary pediatric weight management program. This description will be submitted (on a one time basis) and kept on file with the medical reviewer for each surgeon (and program).
  13. If adolescent, a statement verifying the attainment of physiologic maturity as defined above.
  14. If adolescent, that verification counseling was provided to females regarding potential birth defects from nutritional deficiencies if they become pregnant during the weight stabilization period following surgery.

Bariatric Surgery Revision

Bariatric surgery revision requires a prior authorization.

Required Documentation for Revision of Bariatric Surgery

  1. Date and type of the initial surgery.
  2. Weight loss history after the surgery.
  3. Present height and weight.
  4. Dietary assessment regarding current eating habits.
  5. X-ray or endoscopic report that demonstrates the staple line has failed or the pouch has enlarged.
  6. Psychiatric contraindications to the surgery have been ruled out. If the patient is currently receiving psychiatric treatment, a current diagnostic assessment must be submitted.

Authorization Standards for Sleep Testing

PrimeWest Health covers unattended home sleep studies without prior authorization.

Members with Medicare: PrimeWest Health follows the Medicare billing guidelines for unattended home sleep studies.

Standards for Sleep Testing Adults

PrimeWest Health covers sleep studies as medically necessary for the indications listed below. Service Authorization is not needed before performing sleep testing in adults. Indications for Adult Sleep Study include the following:

  1. Diagnosis of obstructive sleep apnea and other sleep-related breathing disorders
  2. Following a careful exam and history that includes a standardized questionnaire
  3. For patients with high pre-test-probability, an attended cardiorespiratory (Type 3) sleep study is preferable to full-channel polysomnography
  4. Split-night studies should be performed whenever possible
  5. Positive airway pressure titration for patients already diagnosed with sleep apnea or other sleep-related breathing disorders
  6. Follow-up sleep studies to assess treatment for sleep apnea or other sleep-related breathing disorders
  7. Neuromuscular disorders with sleep-related symptoms, which are not adequately diagnosed through sleep history, assessment of sleep hygiene, and review of sleep diaries
  8. Suspected narcolepsy
  9. Parasomnias (cases of dangerous, violent or injurious behavior, seizure cases with inconclusive electroencephalogram [EEG], and atypical parasomnias)
  10. Periodic limb movement disorder (PLMD)

Covered Services

In-lab sleep testing must meet the following criteria to be considered medically necessary: 

  • Be conducted in an accredited sleep laboratory
  • Be attended by a trained sleep specialist
  • Be conducted following a careful exam and history that includes a standardized questionnaire

Attended in-home (portable) sleep studies are covered only in cases where the member is unable to undergo an in-lab study due to circumstances such as the following:

  • Nonambulation
  • Severe and persistent mental illness

Unattended home sleep studies are covered under the following special circumstances for adults ages 18 and over:

  • For members unable to conduct the study in the sleep laboratory due to immobility, safety or critical illness.
  • For follow-up studies for members with no comorbid conditions when diagnosis has been established by standard polysomnography and therapy, and there is a material change in the member’s symptoms or complaints. Follow-up studies may also be covered to monitor the response to non-CPAP treatments for sleep apnea.
  • To rule out sleep apnea when presentation of symptoms or complaints of obstructive sleep apnea (OSA) may be present.
  • When initiation of treatment is urgent and standard polysomnography is not readily available.

All home sleep studies must be under the supervision of the accredited hospital-based sleep lab or sleep clinic that is a direct extension of the physician’s office or an independent diagnostic testing facility.

Types of monitors considered medically necessary for members suggestive of OSA when performing a home sleep study as part of a comprehensive sleep evaluation include the following:

  • Type II devices (greater than or equal to seven channels); or
  • Type IV devices (sleep testing devices measuring three or more channels, one of which is airflow, is covered when used to aid the diagnosis of members who have signs and symptoms indicative of OSA), or
  • Devices that measure three or more channels that include pulse oximetry, actigraphy, and peripheral arterial tone when used to assist in the diagnosis of members who have signs and symptoms indicative of OSA (e.g., Watch-PAT devices).

Providers must provide adequate and proper education to members for unattended home sleep tests. The education must be documented in the medical record.

Sleep studies using devices that do not provide a measurement of apnea-hypopnea index (AHI) and oxygen saturation are considered not medically necessary because they do not provide sufficient information to prescribe treatment.

Noncovered Services

Unattended home sleep tests are not covered for the diagnosis of OSA in members with significant comorbid medical conditions or comorbid sleep disorders that may degrade the accuracy of the test. This includes, but is not limited to, moderate to severe pulmonary disease, neuromuscular disease, or congestive heart failure.

Sleep testing is not covered as a general screening for members who are asymptomatic and is considered not medically necessary.

Unattended sleep studies are not covered when the member has a negative or inconclusive home sleep apnea test. If the member continues to have clinical symptoms of OSA, the member should have an attended in-laboratory polysomnography.

Repeat home sleep testing is considered not medically necessary.

Authorization Standards for Breast MRI

PrimeWest Health covers breast MRIs when certain criteria are met. Procedure codes requiring authorization include the following: 0159T, 77058, 77059, C8903, C8904, C8905, C8906, C8907, and C8908.

Authorization Standards for Breast Reduction

Breast reduction requires a prior authorization.

The following documentation must be submitted with the authorization request:

  1. Chart notes from the referring or primary physician, including:
    1. Clinical history/case summary documenting patient complaints; and
    2. Severity and duration of complaints
  2. Height and weight
  3. Bra size
  4. Previous treatment
  5. Number of grams to be removed from each breast
  6. Photograph
  7. Schnur scale

Authorization Standards for Panniculectomy

Panniculectomy requires prior authorization from PrimeWest Health. It is the responsibility of the provider to submit the authorization request with documentation to support the request. PrimeWest Health follows InterQual™ for these requests.

Authorization Standards for Breast Implant Removal

The following information must be submitted with the authorization request:

  1. Reason for initial implantation
  2. Chart notes/test results documenting leakage/rupture, if present
  3. If rupture is not present, chart notes from the primary or referring physician documenting any medical reasons/symptoms for implant removal (history/case summary, severity and duration, previous treatment)

Authorization Standards for Gynecomastia

Gynecomastia surgery requires a prior authorization.

The following information must be submitted with the authorization request:

  1. Current history and physical examination from the primary care physician
  2. History of medication or drug use
  3. Results of lab tests, to rule out endocrine abnormalities
  4. Evidence that other diseases (which can cause this condition) have been ruled out
  5. Height and weight
  6. Photograph
  7. Pathology report documenting removal of breast tissue rather than fat

Authorization Standards for Botulinum Toxin

The following botulinum toxin products are covered for non-cosmetic indications as noted below. 

Note: These products are distinct and their dosing units are not interchangeable with other botulinum toxin agents. The dosing units of each product cannot be compared to, nor converted from, one product to any other botulinum toxin product. Cosmetic procedures are excluded from coverage. Any use of Botox® for cosmetic indications is not covered.

  • Onabotulinum toxin A (Botox®) is FDA-approved for the following indications: 
    • Treatment of cervical dystonia in adults to reduce the severity of abnormal head position and neck pain
    • Treatment of strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII (facial) nerve disorders in patients age 12 and over
    • Treatment of upper limb spasticity in adults to decrease the severity of increased muscle tone in elbow, wrist, finger, and thumb flexors
    • Treatment of lower limb spasticity in adults to decrease the severity of increased muscle tone in ankle and toe flexors
    • Prophylaxis of headaches in adults with chronic migraines (>15 days per month with headache lasting 4 hours a day or longer)
    • Treatment of severe primary axillary hyperhidrosis that is inadequately managed with topical agents in adults
    • Treatment of urinary incontinence due to detrusor overactivity associated with a neurologic condition (e.g., spinal cord injury [SCI], multiple sclerosis [MS]) in adults who have an inadequate response to or are intolerant of an anticholinergic medication
    • Treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency, in adults who have an inadequate response to or are intolerant of an anticholinergic medication

All other uses of onabotulinum toxin A are considered experimental/investigative due to the lack of clinical evidence demonstrating an impact on improved health outcomes and are not covered.

  • Abobotulinum toxin A (Dysport®) is FDA-approved for the following indications:
    • Treatment of cervical dystonia in adults
    • Treatment of spasticity in adults
    • Treatment of lower limb spasticity in pediatric patients age 2 and over

All other uses of abobotulinum toxin A are considered experimental/investigative due to the lack of clinical evidence demonstrating an impact on improved health outcomes and are not covered.

  • Incobotulinum toxin A (Xeomin®) is FDA-approved for the following indications:
    • Treatment of cervical dystonia in adults, in both botulinum toxin-naïve and previously treated patients 
    • Treatment of blepharospasm in adults who were previously treated with onabotulinum toxin A (Botox®)
    • Treatment of upper limb spasticity in adults 

All other uses of incobotulinum toxin A are considered experimental/investigative due to the lack of clinical evidence demonstrating an impact on improved health outcomes and are not covered.

  • Rimabotulinum toxin B (Myobloc®) is FDA-approved for treatment of cervical dystonia in adults to reduce the severity of abnormal head position and neck pain. 

All other uses of rimabotulinum toxin B are considered experimental/investigative due to the lack of clinical evidence demonstrating an impact on improved health outcomes and are not covered.

Excluded from Coverage
PrimeWest Health does not cover Onabotulinum toxin A (Botox®) for cosmetic purposes, including the following:

  • Temporary improvement in the appearance of moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity in adults
  • Temporary improvement in the appearance of moderate to severe lateral canthal lines associated with orbicularis oculi activity in adults
  • Temporary improvement in the appearance of moderate to severe forehead lines associated with frontalis muscle activity in adults

PrimeWest Health does not cover abobotulinum toxin A (Dysport®) for cosmetic purposes, including the following:

  • Temporary improvement in the appearance of moderate to severe glabellar lines associated with procerus and corrugator muscle activity in adults under age 65. 

PrimeWest Health does not cover incobotulinum toxin A (Xeomin®) for cosmetic purposes, including the following:

  • Temporary improvement in the appearance of moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity in adults. 

Authorization 
Prior authorization is not required; however, services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial may result if criteria are not met. Experimental/investigative and cosmetic services are not eligible for reimbursement. 

Billing
Use current applicable CPT/HCPCS code(s). The following codes are for informational purposes only, and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. 

Onabotulinumtoxin A (Botox®) – J0585, 1 unit = 1 billable unit
Abobotulinumtoxin A (Dysport®) – J0586, 5 units = 1 billable unit
Rimabotulinumtoxin B (Myobloc®) – J0587, 100 units = 1 billable unit
Incobotulinumtoxin A (Xeomin®) – J0588, 1 unit = 1 billable unit

Authorization Standards for Male Circumcision

PrimeWest Health only covers male circumcision when the procedure is medically necessary (in the opinion of the attending physician, a pathologic condition exists where circumcision is required), and is prior authorized.

Circumcision is not covered in the newborn period (up to 28 days of life). Circumcision after the newborn period requires a Service Authorization for determination of medical necessity. Provide documentation of the condition, the symptoms, and the treatment that has been tried.

Authorization Standards for Outpatient High Technology Imaging Services

PrimeWest Health covers medically necessary outpatient high technology imaging including MRIs, magnetic resonance angiograms (MRAs), computed tomography (CT), computed tomography angiography (CTA), and positron emission tomography (PET).

Authorization Standards for Hysterectomy

Procedure codes: 58150, 58152, 58180, 58200, 58210, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58578, and 59525.

A hysterectomy is a medically necessary procedure or operation for the purpose of removing the uterus. PrimeWest Health does not cover hysterectomy for sterilization purposes.

PrimeWest Health does not require prior authorization for this procedure. PrimeWest Health will periodically perform audits of claims paid for this service. In the event it is determined medical necessity for the procedure was not met, PrimeWest Health will re-adjudicate the claim. If a facility continues to perform procedures and medical necessity is not met, that facility will be required to obtain a Service Authorization prior to performing this procedure.

PrimeWest Health requires the provider to secure member authorization to perform a hysterectomy by informing the individual (and her representative, if applicable) that the hysterectomy will make her permanently incapable of reproducing.

A hysterectomy acknowledgement statement (HAS) must be kept in the member's medical record. An example of the HAS can be found in Physician and Professional Services – Covered Services.

Conditions supporting medical necessity for hysterectomy may include, but are not limited to, the following:

  1. Malignant disease of the cervix, uterus, ovaries, or fallopian tubes
  2. Symptomatic uterine fibroids (leiomyomas) that are either:
    1. causing bladder pressure, pain, fullness, functional disturbance,
    2. bleeding unresponsive to conservative therapy; or
    3. showing rapid and progressive enlargement.
  3. Recurrent or persistent uterine bleeding or discharge with failure to respond to conservative management
  4. Confirmed diagnosis of endometriosis with documented failure of non-surgical management (e.g., use of hormonal therapy, if not contraindicated, and/or low dose contraceptives)
  5. Endometritis that is unresponsive to conservative management
  6. Chronic pelvic inflammatory disease unresponsive to conservative management
  7. Adenomatous endometrial hyperplasia with moderate or severe atypia recurring despite conservative management
  8. Obstetrical catastrophes, such as uncontrollable postpartum bleeding, uterine rupture, uncontrolled uterine sepsis developing from septic abortion, placenta accretion, etc.
  9. Septic abortion not responsive to conservative management
  10. Removal of the uterus in non-gynecologic pelvic surgery where necessary to encompass disease originating elsewhere, as in uterine involvement in colon cancer or in abscess secondary to diverticulitis.
  11. Symptomatic uterine prolapse or descent resulting in general pelvic relaxation
  12. Other conditions determined to be medically necessary

Authorization Standards for Spinal Fusions

PrimeWest Health covers cervical, thoracic, and lumbar spinal fusions when medical necessity criteria are met. All spinal fusion procedure codes require a Service Authorization before they can be performed. PrimeWest Health uses InterQual™ criteria as a guideline for medical necessity determinations.

Documentation demonstrating that conservative treatment occurred is still required per PrimeWest Health’s Service Authorization criteria. A practitioner statement alone stating that conservative treatment measures were completed is not sufficient.

Documentation Required

  1. Condition (acute trauma, osteomyelitis, tumor, etc.), indication of instability confirmed by radiographic (or imaging) studies
  2. If a tumor or lesion needs excision, indication if excision will cause vertebral instability
  3. Current symptoms
  4. Treatment tried in the past, for how long, and response to treatment
  5. Interference with ADLs (for non-traumatic instability and degenerative conditions)

Authorization Standards for BRCA Genetic Mutation Testing for Breast and Ovarian Cancer Susceptibility

PrimeWest Health covers genetic mutation testing for breast and cervical cancer susceptibility when certain criteria are met. Procedure codes that require authorization include: S3818 – S3823 and 83890 – 83909 with modifier 0A or 0B. BRCA mutation testing must be conducted in conjunction with pre- and post-test genetic counseling by a physician or a licensed or a certified genetic counselor.

BRCA genetic mutation testing will be approved in cases where the results will impact the care of the individual patient (member). Criteria in either 1 or 2 below must be met:

  1. Member is identified as high-risk for a BRCA mutation:
    1. For women of Ashkenazi Jewish descent (or other ethnicity/population for which “founder” mutations in the BRCA genes have been identified):
      1. Any first-degree relative (or two second-degree relatives on the same side of the family) with breast or ovarian cancer*
    2. For women of ethnicities not described above (one or more of the following):
      1. Two first-degree relatives with breast cancer, one of whom was diagnosed at age 50 or younger
      2. A combination of three or more first- or second-degree relatives with breast cancer regardless of age of diagnosis
      3. Any combination of breast and ovarian cancer among any combination of first- and second-degree relatives
      4. A first-degree relative with bilateral breast cancer
      5. A combination of two or more first- and second-degree relatives with ovarian cancer, regardless of age of diagnosis
      6. A first or second-degree relative with both breast and ovarian cancer at any age
      7. History of breast cancer in a male relative
      8. Member has personal history of breast or ovarian cancer and wishes to inform future reproductive decision-making

*A first-degree relative is an individual’s parent, sibling, or child. A second-degree relative is an individual’s aunt, uncle, grandparent, grandchild, niece, nephew, or half sibling.

Authorization Standards for Radiofrequency Neuroablation for Facet-Mediated Back and Neck Pain

PrimeWest Health covers radiofrequency neuroablation to treat facet-mediated back and neck pain when certain criteria are met. No authorization is required when this procedure is done for chronic cervical or lumbar facet-mediated spinal pain. Procedure codes that require authorization include: 64633, 64634, and 64640. Authorization is required when the procedure is planned for conditions that are not limited to the cervical or lumbar spine (authorization required if the procedure is for the thoracic spine). Authorization is required before performing radiofrequency neuroablation for any area of the body that is not the cervical or lumbar spine.

Radiofrequency nerve root ablation may be medically necessary for chronic cervical or lumbar facet-mediated spinal pain that is refractory to conservative therapy. The procedure must be conducted under fluoroscopic guidance to assure proper needle positioning.

Documentation needed

  1. Presence of any neurologic symptoms or findings
  2. Indication that the member has facet-mediated spinal pain diagnosed by comparative, controlled medial branch nerve blocks (two or more facet joint injections). The diagnostic nerve blocks must:
    1. Provide more than 50 percent pain relief using the Visual Analog Scale (VAS) or other validated tool (at least one hour for lidocaine and two hours for bupivacaine) during follow-up assessment
    2. Not be conducted under intravenous sedation unless specifically indicated
    3. Not include steroid injections
  3. Written description of diagnostic procedure and patient response including degree of pain relief and, if applicable, indications for sedation
  4. Facet-mediated pain has been unresponsive to appropriate conservative therapy. Describe prior therapies attempted and patient’s response (such as structured exercise, PT, activity modification, pharmacological management, therapeutic nerve blocks, and joint injections) for a period of at least six months.

For repeat procedure (same level), documentation required includes:

  1. Date of last radiofrequency nerve root ablation treatment (repeat procedures can be approved at intervals of no less than three months)
  2. Patient response to the last radiofrequency nerve root ablation including degree of pain relief. (Repeat procedure may be approved if the member obtained greater than 50 percent relief using the VAS or other validated tool for at least 10 – 12 weeks following the previous procedure.)
  3. No more than three procedures per a 12-month period will be approved.

Endovenous Radiofrequency Ablation

Endovenous radiofrequency ablation for the treatment of varicose veins requires authorization. Bill for this service using codes 36475 and 36478.

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Updated_04/24/2024