Lumbar Decompression - (Effective Date - 2026-10-15) 7.01.113

By October 15, 2026: (1) Billing team must implement prior authorization requirements in billing system for all lumbar decompression procedures—update system rules to flag claims for manual review if prior auth is missing. (2) Providers must obtain prior authorization BEFORE scheduling lumbar decompression, interlaminar decompression device placement (Coflex), or lumbar corpectomy procedures. (3) Update encounter forms and pre-op checklists to require documentation of: failed conservative treatment (minimum 2 of 3 options: PT/exercise, prescription medications, or epidural steroid injections—each for 6 weeks minimum); imaging studies (MRI/CT) showing neural compression concordant with symptoms; and absence of unmanaged mental/behavioral health disorders. (4) Establish verification process to confirm imaging is interpreted by independent radiologist and reconcile any discrepancies with surgeon's interpretation before submission. (5) Create denial prevention checklist: do NOT submit claims for decompression performed ONLY for annular tears, discography results, MR spectroscopy, or degenerative disc disease alone—these are non-covered indications. (6) Do NOT bill for interlaminar decompression device (Coflex) if used with lumbar fusion at same level, with Meyerding Grade 2+ spondylolisthesis, with spondylolysis/isthmic spondylolisthesis, or in non-open procedures. Failure to obtain prior authorization or submit required documentation will result in claim denials.