Lumbar Decompression 7.01.113

REQUIREMENTS: By October 15, 2025 (IMMEDIATELY - policy is 1 day old): Billing team must implement mandatory prior authorization process for ALL lumbar decompression procedures billed to Excellus BlueCross BlueShield. Specifically: 1. Update billing system to flag and route ALL lumbar decompression claims for prior auth approval before processing or submission. 2. Create prior authorization checklist requiring providers to submit: - CPT codes, disc levels, and ICD-10 codes - Detailed documentation of conservative treatment trials (type, duration, frequency, response for each of: physical therapy, prescription medications [analgesics/steroids/gabapentinoids/NSAIDs], and/or epidural steroid injections or nerve blocks) - Written proof that patient achieved LESS than 50% global improvement on at least 2 of 3 modalities (or documentation of medical contraindication) - Radiologist-signed imaging reports (MRI/CT/myelography only—reject discography and MR spectroscopy) - Documentation confirming absence of unmanaged depression, chronic pain syndrome, or opioid/alcohol use disorders - Clarification of procedure type: neurogenic claudication vs. radiculopathy (different criteria apply) 3. Billing team must DENY claims without complete prior auth documentation or that contain: - Annular tears as sole indication - Concordant discography results - MR spectroscopy results - Degenerative disc disease alone - Interlaminar decompression devices (Coflex) used with lumbar fusion, at >2 levels, with Grade 2+ spondylolisthesis, or percutaneously - Investigational devices: interspinous spacers (Superion, X-STOP, TOPS) 4. Providers must reconcile any discrepancies between surgeon and radiologist imaging interpretations in submitted documentation. 5. Flag urgent/emergent exceptions (cauda equina syndrome, unstable fractures with neural compression, progressive neurological deficits on serial exams) that may bypass standard criteria—these require imaging findings and immediate review. 6. For repeat decompression at same level: require 12+ weeks elapsed time AND re-demonstrate all initial criteria are met. Consequences of inaction: Claims will be denied for lack of prior authorization or incomplete documentation. Patients may dispute denials, and practice may face claim payment delays and reduced reimbursement.