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Change to Prior Authorization Process for Orthopedic and Spinal Procedures

Date: 08/06/19

Trillium Community Health Plan (Trillium) is pleased to announce the launch of a new and innovative Surgical Quality and Safety Management Program, effective 10/1/2019.

Prior Authorization for medical necessity and appropriate length of stay (when applicable) has been delegated to TurningPoint Healthcare Solutions, LLC and will be required for the following surgical procedures in both inpatient and outpatient settings.

KEY PROVISIONS:

  • Emergency-related procedures do not require authorization
  • It is the responsibility of the ordering physician to obtain authorization
  • Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claims.

We appreciate your support and look forward to your cooperation in assuring that Trillium members receive high-quality, cost-effective care for these surgical procedures.

TurningPoint’s Contact Information:

Inpatient and outpatient services requiring prior authorization:

This is not a complete list of services requiring authorization. This is a summary of changes. Please review the Pre-Auth Check Tool at trilliumohp.com/providers/preauth-check to confirm prior authorization requirements, or contact TurningPoint at the numbers above.

Code

Description

Code Type

Trillium OHP

Medicare Advantage

20930

Allograft, morselized, or placement of osteopromotive material, for spine surgery only

CPT

PA now required

PA now required

20931

Allograft, structural, for spine surgery only

CPT

PA now required

PA now required

20936

Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision

CPT

PA now required

PA now required

20937

Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision)

CPT

PA now required

PA now required

20938

Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision

CPT

PA now required

PA now required

22100

Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical

CPT

PA now required

PA now required

22325

Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; lumbar

CPT

PA now required

PA now required

22326

Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; cervical

CPT

PA now required

PA now required

22327

Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; thoracic

CPT

PA now required

PA now required

22328

Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; each additional fractured vertebra or dislocated segment

CPT

PA now required

PA now required

22899

Unlisted procedure, spine

CPT

PA now required

PA required

23130

Acromioplasty Or Acromionectomy, Partial, With Or Without Coracoacromial Ligament Release

CPT

PA now required

PA now required

23333

Removal of foreign body, shoulder; deep (subfascial or intramuscular)

CPT

PA now required

PA now required

23334

Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid component

CPT

PA now required

PA now required

23335

Removal of prosthesis, includes debridement and synovectomy when performed; humeral and glenoid components (eg, total shoulder)

CPT

PA now required

PA now required

23410

Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute

CPT

PA now required

PA now required

23412

Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic

CPT

PA now required

PA now required

23415

Coracoacromial Ligament Release, With Or Without Acromioplasty

CPT

PA now required

PA now required

23420

Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)

CPT

PA now required

PA now required

23616

Open Treatment Of Proximal Humeral (Surgical Or Anatomical Neck) Fracture, Includes Internal Fixation, When Performed, Includes Repair Of Tuberosity(S), When Performed; With Proximal Humeral Prosthetic Replacement

CPT

PA now required

PA now required

23800

Arthrodesis, glenohumeral joint;

CPT

PA now required

PA now required

23802

Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft)

CPT

PA now required

PA now required

24160

Removal of prosthesis, includes debridement and synovectomy when performed; humeral and ulnar components

CPT

PA now required

PA now required

24164

Removal of prosthesis, includes debridement and synovectomy when performed; radial head

CPT

PA now required

PA now required

24365

Arthroplasty, radial head

CPT

PA now required

PA required

25800

ARTHRODESIS WRIST COMPLETE W/O BONE GRAFT

CPT

PA now required

PA now required

25805

ARTHRODESIS WRIST W/SLIDING GRAFT

CPT

PA now required

PA now required

25810

ARTHRODESIS WRIST W/ILIAC/OTHER AUTOGRAFT

CPT

PA now required

PA now required

25820

ARTHRODESIS WRIST LIMITED W/O BONE GRAFT

CPT

PA now required

PA now required

25825

ARTHRODESIS WRIST LIMITED W/AUTOGRAFT

CPT

PA now required

PA now required

27033

Arthrotomy, hip, including exploration or removal of loose or foreign body

CPT

PA now required

PA now required

27090

Removal of hip prothesis

CPT

PA now required

PA now required

27091

Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacer

CPT

PA now required

PA now required

27120

Hip Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type)

CPT

PA now required

PA required

27122

Hip Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure)

CPT

PA now required

PA required

27280

Arthrodesis, sacroiliac joint (including obtaining graft)

CPT

PA now required

PA now required

27299

Unlisted procedure, pelvis or hip joint [when specified as open procedure for femoroacetabular impingement syndrome, other than capsular plication]

CPT

PA now required

PA now required

27360

Partial excision (craterization, saucerization, or diaphysectomy) bone, femur, proximal tibia and/or fibula (eg, osteomyelitis or bone abscess

CPT

PA now required

PA now required

27405

Repair, primary, torn ligament and/or capsule, knee; collateral

CPT

PA now required

PA now required

27407

Repair, primary, torn ligament and/or capsule, knee; cruciate

CPT

PA now required

PA now required

27409

Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments

CPT

PA now required

PA now required

27412

Autologous chondrocyte implantation, knee

CPT

PA now required

PA required

27415

Osteochondral allograft, knee, open [when specified as osteochondral allograft]

CPT

PA now required

PA now required

27416

Osteochondral autograft(s), knee, open (eg, mosaicplasty) includes harvesting of autograft[s])

CPT

PA now required

PA required

27488

Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee

CPT

PA now required

PA now required

27700

Arthroplasty, ankle

CPT

PA now required

PA now required

27870

Arthrodesis, ankle, open

CPT

PA now required

PA now required

29826

Arthroscopy, Shoulder, Surgical; Decompression Of Subacromial Space With Partial Acromioplasty, With Coracoacromial Ligament (Ie, Arch) Release, When Performed (List Separately In Addition To Code For Primary Procedure)

CPT

PA now required

PA now required

29827

Arthroscopy, shoulder, surgical; with rotator cuff repair

CPT

PA now required

PA now required

29860

Arthroscopy, Hip, Diagnostic With Or Without Synovial Biopsy (Separate Procedure)

CPT

PA now required

PA now required

29861

Arthroscopy, Hip, Surgical; With Removal Of Loose Body Or Foreign Body

CPT

PA now required

PA now required

29862

Arthroscopy, Hip, Surgical; With Debridement/Shaving Of Articular Cartilage (Chondroplasty), Abrasion Arthroplasty, And/Or Resection Of Labrum

CPT

PA now required

PA now required

29863

Arthroscopy, Hip, Surgical; With Synovectomy

CPT

PA now required

PA now required

29866

Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft)

CPT

PA now required

PA required

29867

Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty)

CPT

PA now required

PA required

29868

Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral

CPT

PA now required

PA now required

29870

Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)

CPT

PA now required

PA now required

29871

Arthroscopy, knee, surgical; for infection, lavage and drainage

CPT

PA now required

PA now required

29873

Arthroscopy, knee, surgical; with lateral release

CPT

PA now required

PA now required

29874

Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)

CPT

PA now required

PA now required

29875

Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)

CPT

PA now required

PA now required

29876

Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral)

CPT

PA now required

PA now required

29877

Arthroscopy, knee, surgical; debridement/ shaving or articular cartilage (chondroplasty)

CPT

PA now required

PA now required

29879

Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture

CPT

PA now required

PA now required

29880

Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/ shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

CPT

PA now required

PA now required

29881

Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/ shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

CPT

PA now required

PA now required

29882

Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral)

CPT

PA now required

PA now required

29883

Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral)

CPT

PA now required

PA now required

29884

Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure)

CPT

PA now required

PA now required

29885

Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixaiton (including debridement of base of lesion)

CPT

PA now required

PA now required

29886

Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion

CPT

PA now required

PA now required

29887

Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation

CPT

PA now required

PA now required

29888

Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction

CPT

PA now required

PA now required

29889

ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ

CPT

PA now required

PA now required

29899

Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis

CPT

PA now required

PA now required

29914

Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion)

CPT

PA now required

PA now required

29915

Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion)

CPT

PA now required

PA now required

29916

Arthroscopy, hip, surgical; with labral repair [when repair of the labral tear is associated with FAIS]

CPT

PA now required

PA now required

29999

Unlisted procedure, arthroscopy [when specified as arthroscopic knee lavage as a separate procedure]

CPT

PA now required

PA now required

36260

Insertion of implantable intra-arterial infusion pump (eg, for chemotherapy of liver)

CPT

PA now required

PA now required

36563

Insertion Of Tunneled Centrally Inserted Central Venous Access Device With Subcutaneous Pump

CPT

PA now required

PA now required

36583

Replacement, Complete, Of A Tunneled Centrally Inserted Central Venous Access Device, With Subcutaneous Pump, Through Same Venous Access

CPT

PA now required

PA now required

61215

Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter

CPT

PA now required

PA now required

62287

Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar

CPT

PA now required

PA required

63662

Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed

CPT

PA required

PA now required

63663

Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed

CPT

PA now required

PA now required

63664

Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed

CPT

PA now required

PA now required

C1767

Generator, neurostimulator (implantable), non-rechargeable

HCPCS

PA now required

PA now required

C1772

Infusion pump, programmable (implantable)

HCPCS

PA now required

PA now required

C1778

Lead, neurostimulator (implantable)

HCPCS

PA now required

PA now required

C1787

Patient programmer, neurostimulator

HCPCS

PA now required

PA now required

C1820

Generator, neurostimulator (implantable), with rechargeable battery and charging system

HCPCS

PA now required

PA now required

C1883

Adaptor/extension, pacing lead or neurostimulator lead (implantable)

HCPCS

PA now required

PA now required

C1891

Infusion pump, nonprogrammable, permanent (implantable)

HCPCS

PA now required

PA now required

C1897

Lead, neurostimulator test kit (implantable)

HCPCS

PA now required

PA now required

C2626

Infusion pump, nonprogrammable, temporary (implantable)

HCPCS

PA now required

PA now required

G0289

Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee

HCPCS

PA now required

PA now required

L8685

Implantable neurostimulator pulse generator, single array, rechargeable, includes extension

HCPCS

PA now required

This is not a Medicare Covered procedure or service.

L8695

External recharging system for battery (external) for use with implantable neurostimulator, replacement only

HCPCS

PA now required

PA now required

S2112

Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)

HCPCS

PA now required

PA required

S2118

METL-ON-METL TOT HIP RESRFC ACETAB&FEM CMPNT

HCPCS

PA now required

This is not a Medicare Covered procedure or service.