Change to Prior Authorization Process for Orthopedic and Spinal Procedures

Date: 08/06/19

19-025 This update applies to Medicare Advantage products

Health Net Health Plan of Oregon (Health Net) 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:

Web Portal: http://www.myturningpoint-healthcare.com
Email: centeneORum@turningpoint-healthcare.com
Phone: 971.300.0597 and toll-free 844.245.6518
Fax: 971.285.4207

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 or.healthnetadvantage.com/for-providers/medicare-pre-auth to confirm prior authorization requirements, or contact TurningPoint at the numbers above.

Code	Description	Code Type	Medicare Advantage (PPO & HMO)
20930	Allograft, morselized, or placement of osteopromotive material, for spine surgery only	CPT	PA now required
20931	Allograft, structural, for spine surgery only	CPT	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
20937	Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision)	CPT	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
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
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
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
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
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
22899	Unlisted procedure, spine	CPT	PA required
23130	Acromioplasty Or Acromionectomy, Partial, With Or Without Coracoacromial Ligament Release	CPT	PA now required
23333	Removal of foreign body, shoulder; deep (subfascial or intramuscular)	CPT	PA now required
23334	Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid component	CPT	PA now required
23335	Removal of prosthesis, includes debridement and synovectomy when performed; humeral and glenoid components (eg, total shoulder)	CPT	PA now required
23410	Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute	CPT	PA now required
23412	Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic	CPT	PA now required
23415	Coracoacromial Ligament Release, With Or Without Acromioplasty	CPT	PA now required
23420	Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)	CPT	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
23800	Arthrodesis, glenohumeral joint;	CPT	PA now required
23802	Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft)	CPT	PA now required
24160	Removal of prosthesis, includes debridement and synovectomy when performed; humeral and ulnar components	CPT	PA now required
24164	Removal of prosthesis, includes debridement and synovectomy when performed; radial head	CPT	PA now required
24365	Arthroplasty, radial head	CPT	PA required
25800	ARTHRODESIS WRIST COMPLETE W/O BONE GRAFT	CPT	PA now required
25805	ARTHRODESIS WRIST W/SLIDING GRAFT	CPT	PA now required
25810	ARTHRODESIS WRIST W/ILIAC/OTHER AUTOGRAFT	CPT	PA now required
25820	ARTHRODESIS WRIST LIMITED W/O BONE GRAFT	CPT	PA now required
25825	ARTHRODESIS WRIST LIMITED W/AUTOGRAFT	CPT	PA now required
27033	Arthrotomy, hip, including exploration or removal of loose or foreign body	CPT	PA now required
27090	Removal of hip prothesis	CPT	PA now required
27091	Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacer	CPT	PA now required
27120	Hip Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type)	CPT	PA required
27122	Hip Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure)	CPT	PA required
27280	Arthrodesis, sacroiliac joint (including obtaining graft)	CPT	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
27360	Partial excision (craterization, saucerization, or diaphysectomy) bone, femur, proximal tibia and/or fibula (eg, osteomyelitis or bone abscess	CPT	PA now required
27405	Repair, primary, torn ligament and/or capsule, knee; collateral	CPT	PA now required
27407	Repair, primary, torn ligament and/or capsule, knee; cruciate	CPT	PA now required
27409	Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments	CPT	PA now required
27412	Autologous chondrocyte implantation, knee	CPT	PA required
27415	Osteochondral allograft, knee, open [when specified as osteochondral allograft]	CPT	PA now required
27416	Osteochondral autograft(s), knee, open (eg, mosaicplasty) includes harvesting of autograft[s])	CPT	PA required
27488	Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee	CPT	PA now required
27700	Arthroplasty, ankle	CPT	PA now required
27870	Arthrodesis, ankle, open	CPT	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
29827	Arthroscopy, shoulder, surgical; with rotator cuff repair	CPT	PA now required
29860	Arthroscopy, Hip, Diagnostic With Or Without Synovial Biopsy (Separate Procedure)	CPT	PA now required
29861	Arthroscopy, Hip, Surgical; With Removal Of Loose Body Or Foreign Body	CPT	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
29863	Arthroscopy, Hip, Surgical; With Synovectomy	CPT	PA now required
29866	Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft)	CPT	PA required
29867	Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty)	CPT	PA required
29868	Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral	CPT	PA now required
29870	Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)	CPT	PA now required
29871	Arthroscopy, knee, surgical; for infection, lavage and drainage	CPT	PA now required
29873	Arthroscopy, knee, surgical; with lateral release	CPT	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
29875	Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)	CPT	PA now required
29876	Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral)	CPT	PA now required
29877	Arthroscopy, knee, surgical; debridement/ shaving or articular cartilage (chondroplasty)	CPT	PA now required
29879	Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture	CPT	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
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
29882	Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral)	CPT	PA now required
29883	Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral)	CPT	PA now required
29884	Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure)	CPT	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
29886	Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion	CPT	PA now required
29887	Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation	CPT	PA now required
29888	Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction	CPT	PA now required
29889	ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ	CPT	PA now required
29899	Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis	CPT	PA now required
29914	Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion)	CPT	PA now required
29915	Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion)	CPT	PA now required
29916	Arthroscopy, hip, surgical; with labral repair [when repair of the labral tear is associated with FAIS]	CPT	PA now required
29999	Unlisted procedure, arthroscopy [when specified as arthroscopic knee lavage as a separate procedure]	CPT	PA now required
36260	Insertion of implantable intra-arterial infusion pump (eg, for chemotherapy of liver)	CPT	PA now required
36563	Insertion Of Tunneled Centrally Inserted Central Venous Access Device With Subcutaneous Pump	CPT	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
61215	Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter	CPT	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 required
63662	Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed	CPT	PA now required
63663	Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed	CPT	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
C1767	Generator, neurostimulator (implantable), non-rechargeable	HCPCS	PA now required
C1772	Infusion pump, programmable (implantable)	HCPCS	PA now required
C1778	Lead, neurostimulator (implantable)	HCPCS	PA now required
C1787	Patient programmer, neurostimulator	HCPCS	PA now required
C1820	Generator, neurostimulator (implantable), with rechargeable battery and charging system	HCPCS	PA now required
C1883	Adaptor/extension, pacing lead or neurostimulator lead (implantable)	HCPCS	PA now required
C1891	Infusion pump, nonprogrammable, permanent (implantable)	HCPCS	PA now required
C1897	Lead, neurostimulator test kit (implantable)	HCPCS	PA now required
C2626	Infusion pump, nonprogrammable, temporary (implantable)	HCPCS	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
L8685	Implantable neurostimulator pulse generator, single array, rechargeable, includes extension	HCPCS	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
S2112	Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)	HCPCS	PA required
S2118	METL-ON-METL TOT HIP RESRFC ACETAB&FEM CMPNT	HCPCS	This is not a Medicare Covered procedure or service.