Commercial

Medical Policy

Notification

Musculoskeletal Services (Independence)

Notification Issue Date:

This version of the policy will become effective 04/09/2023.

AIM has changed their name to “Carelon Medical Benefits Management" effective 03/01/2023.

Carelon Medical Benefits Management formerly AIM Specialty Health® (AIM) has revised their Clinical Appropriateness Guidelines for Musculoskeletal-Interventional Pain Management. For a detailed summary of changes, see the specific guidelines which will become effective 04/09/2023. These guidelines are available online at: https://aimspecialtyhealth.com/resources/clinical-guidelines/musculoskeletal/html.

Title:

Musculoskeletal Services (Independence)

Policy #:

00.01.66r

​

Policy

This policy does not apply to Members for whom the Carelon Medical Benefits Management Musculoskeletal Services Program is not applicable. This policy only applies to members for whom the Program is applicable. Individual member benefits must be verified before/prior to providing services.

The intent of this policy is to communicate that the Company has delegated the responsibility for utilization management activities to Carelon Medical Benefits Management for select musculoskeletal services that will be based upon

Carelon’s Clinical Appropriateness Guidelines.

Experimental and investigational services are services whose safety or efficacy is not known, or are services that are used in a way that departs from generally accepted standards of practice in the medical community. As such, precertification/preapproval for these procedures may be denied by Carelon as not medically necessary (NMN) when Carelon uses its clinical guidelines.

Refer to the References section of this policy for a link to the Carelon Medical Benefits Management Appropriateness Guidelines for the spinal surgical procedures, joint surgical procedures, and interventional pain management procedures that are part of this program. Refer to Attachments A, B, and C of this policy for a complete list of codes that require precertification for spinal surgical procedures, joint surgical procedures, and interventional pain management procedures, respectively.

SPINAL SURGICAL PROCEDURES

Carelon Medical Benefits Management will utilize their Clinical Appropriateness Guidelines to determine medical necessity for the following procedures:

Cervical Decompression With or Without Fusion
Cervical Disc Arthroplasty
Lumbar Discectomy, Foraminotomy, and Laminotomy
Lumbar Fusion and Treatment of Spinal Deformity (including Scoliosis and Kyphosis)
Lumbar Laminectomy
Lumbar Arthroplasty
Noninvasive Electrical Bone Growth Stimulators (spinal)
Vertebroplasty/Kyphoplasty
Bone Graft Substitutes and Bone Morphogenetic Proteins
Sacroiliac Joint Fusion (percutaneous/minimally invasive techniques)

SURGICAL PROCEDURES OF THE JOINT

Carelon Medical Benefits Management will utilize their Clinical Appropriateness Guidelines to determine medical necessity as described below:

Shoulder Arthroplasty (total/partial/revision shoulder replacement)
Shoulder Arthroscopy and Open Procedures
Hip Arthroplasty (total/partial/revision hip replacement)
Hip Arthroscopy and Open Procedures
Knee Arthroplasty (total/partial/revision knee replacement)
Knee Arthroscopy and Open Procedures
Meniscal Allograft Transplantation of the Knee
Treatment of Osteochondral Defects

INTERVENTIONAL PAIN MANAGEMENT PROCEDURES

Carelon Medical Benefits Management will utilize their Clinical Appropriateness Guidelines to determine medical necessity for the following procedures:

Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks*
Paravertebral Facet Injection/Nerve Block/Neurolysis
Regional Sympathetic Nerve Block
Sacroiliac Joint Injection
Spinal Cord and Nerve Root Stimulators

* Pre-service utilization management is not in place for CPT codes 62320 and 62322, which represent epidural injection procedures, when they are performed for the following three ICD-10-CM diagnoses: G89.11 Acute pain due to trauma, G89.12 Acute post-thoracotomy pain, or G89.18 Other acute post procedural pain.

Carelon will utilize the Company's Experimental/Investigational Services medical policy to determine medical necessity for services not listed in Carelon's Clinical Appropriateness Guidelines.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, spinal surgical procedures, joint surgical procedures, and interventional pain management procedures are covered under the medical benefits of the Company’s products when the medical necessity criteria for the services are met.

Description

The Company has delegated the responsibility for utilization management activities of select spinal surgical procedures, joint surgical procedures, and interventional pain management procedures to Carelon Medical Benefits Management. Carelon uses the Company's medical policies or its Clinical Appropriateness Guidelines to determine medical necessity for the select spinal surgical procedures, joint surgical procedures, and interventional pain management procedures. Multiple sources were used to develop these medical policies and guidelines, including technology assessments, peer-reviewed medical literature, clinical outcomes research, and consensus opinion in medical practice.

References

Carelon Medical Benefits Management Clinical Appropriateness Guidelines: Musculoskeletal. [Carelon Web site]. 11/17/2025. Available at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-musculoskeletal-guidelines/. Accessed: November 5, 2025.

Coding

CPT Procedure Code Number(s)

Refer to Attachments A, B, and C of this policy for a complete list of codes that require preservice utilization management for spinal surgical procedures, joint surgical procedures, and interventional pain management procedures respectively.

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions from 00.01.66r:

01/01/2026

Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.

This policy has been identified and updated for the CPT code update effective 01/01/2026.

The following CPT narrative has been revised: 27279.

The following CPT code has been terminated and removed from this policy: 27445.

Revsions From 00.01.66q:

11/17/2025

This version of the policy will become effective 11/17/2025.

Carelon Medical Benefits Management has revised their Clinical Appropriateness Guidelines for Musculoskeletal-Joint Surgery, Sacroiliac Joint Fusion, and Spine Surgery.

For a detailed summary of changes, see the specific guidelines that will become effective 11/17/2025. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-musculoskeletal-guidelines/.

The following CPT narratives have been revised in Attachment A of this policy:

FROM:
Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure)

TO:
22632: Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar; each additional interspace (List separately in addition to code for primary procedure)

FROM:
22634: Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace; each additional interspace and segment (List separately in addition to code for primary procedure)

TO:
22634: Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace; lumbar; each additional interspace and segment (List separately in addition to code for primary procedure).

Revision From 00.01.66p:

07/25/2025

This version of the policy will become effective 07/25/2025.

Carelon Medical Benefits Management has revised their Clinical Appropriateness Guidelines for Musculoskeletal-Interventional Pain Management.

For a detailed summary of changes, see the specific guidelines that will become effective 07/25/2025. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-musculoskeletal-guidelines/.

Revision From 00.01.66o:

01/01/2025

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

This policy has been identified and updated for the HCPCS code update effective 01/01/2025.

The following HCPCS code has been added to the policy as Medically Necessary:
C1737: Joint fusion and fixation device (s), sacroiliac and pelvis, including all system components (implantable)

Revision From 00.01.66n:

11/17/2024

This version of the policy will become effective 11/17/2024.

Carelon Medical Benefits Management has revised their Clinical Appropriateness Guidelines for Musculoskeletal-Joint Surgery.

For a detailed summary of changes, see the specific guidelines that will become effective 11/17/2024. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-musculoskeletal-guidelines/

Revision From 00.01.66m:

10/20/2024

This version of the policy will become effective 10/20/2024.

Carelon Medical Benefits Management has revised their Clinical Appropriateness Guidelines for Musculoskeletal-Spinal Surgery and Sacroiliac Joint Fusion.

The policy has been revised to communicate the Company's delegation of precertification/preapproval of Artificial Intervertebral Lumbar Disc Insertion to Carelon Medical Benefits Management.

The following procedure codes have been added to Attachment A as medically necessary: 0164t, 0165t, 22865, 22857, 22860, 22862 and 27280.

For a detailed summary of changes, see the specific guidelines that will become effective 10/20/2024. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-musculoskeletal-guidelines/.

Revisions From 00.01.66l:

04/14/2024

This version of the policy will become effective 04/14/2024.

Carelon Medical Benefits Management has revised their Clinical Appropriateness Guidelines for Musculoskeletal-Interventional Pain Management and Sacroiliac Joint Fusion.

The following procedure codes have been added to Attachment A as medically necessary: C7504, C7505, C7507, C7508.

For a detailed summary of changes, see the specific guidelines which will become effective 04/14/2024. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-musculoskeletal-guidelines/

Revisions From 00.01.66k:

01/02/2024

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

This policy has been identified and updated for the CPT code update effective 01/02/2024.

The following CPT narratives have been revised in Attachment C of this policy:

FROM:
63685: Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling

TO:
63685: Insertion or replacement of spinal neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver

FROM:
63688: Revision or removal of implanted spinal neurostimulator pulse generator or receiver

TO:
63688: Revision or removal of implanted spinal neurostimulator pulse generator or receiver, with detachable connection to electrode array

Revisions From 00.01.66j:

11/05/2023

This version of the policy will become effective 11/05/2023.

Carelon Medical Benefits Management has revised their Clinical Appropriateness Guidelines for Musculoskeletal-Joint Surgery.

For a detailed summary of changes, see the specific guidelines that will become effective 11/05/2023. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/joint-surgery-2023-11-05/.

The following procedure codes have been added to Attachment B of this policy as Medically Necessary: S2118, 20932, 20933, 20934

Revisions From 00.01.66i:

09/10/2023

This version of the policy will become effective 09/10/2023.

Carelon Medical Benefits Management has revised their Clinical Appropriateness Guidelines for Musculoskeletal.

For a detailed summary of changes, see the specific guidelines that will become effective 09/10/2023. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-musculoskeletal-guidelines/.

Revisions From 00.01.66h:

04/09/2023

This version of the policy will become effective 04/09/2023.

AIM has changed their name to “Carelon Medical Benefits Management" effective 03/01/2023.

Revisions From 00.01.66g:

11/06/2022

This version of the policy will become effective 11/06/2022.

AIM Specialty Health® (AIM) has revised their Clinical Appropriateness Guidelines for Musculoskeletal-Interventional Pain Management. For a detailed summary of changes, see the specific guidelines which will become effective 11/6/2022. These guidelines are available online at: http://www.aimspecialtyhealth.com/CG-Musculoskeletal.html.

Revisions From 00.01.66f:

09/11/2022

This version of the policy will become effective 09/11/2022.

AIM Specialty Health® (AIM) has revised their Clinical Appropriateness Guidelines for Musculoskeletal. For a detailed summary of changes, see the specific guidelines which will become effective 09/11/2022. These guidelines are available online at: http://www.aimspecialtyhealth.com/CG-Musculoskeletal.html.

The following CPT code has been added to Attachment B of this policy as Medically Necessary: 27345:

Revisions From 00.01.66e:

07/01/2022

This version of the policy will become effective 07/01/2022.

Effective July 1, 2022, the policy disclaimer was revised to communicate:

This policy does not apply to Members for whom the AIM Specialty Health® Musculoskeletal Program is not applicable. This policy only applies to members for whom the Program is applicable. Individual member benefits must be verified before/prior to providing services.

01/01/2022

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

This policy has been identified for the CPT code update, effective 01/01/2022.

The following CPT narratives have been revised in this policy: 22614, 22633 and 22634.

The following CPT codes have been added to the policy: 63052 and 63053.

The following CPT code has been termed from the policy: 63194, 63196, 63198.

Revsions From 00.01.66d:

03/08/2021

This version of the policy will become effective 03/08/2021

The intent of this policy is unchanged, however, the services listed in the 'Experimental/Investigational' section have been removed and continue to reside in the "Experimental/Investigational Services" policy.

Revisions From 00.01.66c:

01/10/2021

This version of the policy will become effective 01/10/2021.

The policy has been updated to communicate the Company's use of AIM Specialty Health® (AIM) Guidelines for select interventional pain management, spinal and joint surgical procedures, for which Company medical policies had been used.

For the topic of artificial intervertebral lumbar disc insertion, Company medical policy bulletin and policy position will continue to be used by AIM Specialty Health® (AIM).

The following CPT codes have been added to attachment B of the policy which lists Joint Surgery Procedure Codes that require preservice utilization management through AIM Specialty Health® (AIM): 27120, 27122, 27437, 27445, 27488 and 29871.

The following CPT code has been removed from attachment A of the policy which lists Spinal Surgery Procedure codes that require preservice utilization management through AIM Specialty Health® (AIM): 22862. CPT code 22862 is Experimental/Investigational and will be included in policy # 11.15.31: "Artificial Intervertebral Lumbar Disc Insertion".

The following CPT codes have revised narratives: 29822, 29823, 64479, 64480, 64483 and 64484.

Revisions From 00.01.66b:

01/14/2019

This version of the policy will become effective on 01/14/2019.

The following services have been added to the Spine Surgical Procedures' section for this utilization management program through AIM:

Sacroiliac Joint Fusion

Pre-service utilization management is not in place for CPT codes 62320 and 62322, which represent epidural injection procedures, when they are performed for the following three ICD-10-CM diagnoses: G89.11 Acute pain due to trauma, G89.12 Acute post-thoracotomy pain, or G89.18 Other acute post procedural pain.

This policy does not apply to those members for whom Independence Administrators serves as the claims administrator or to the Company's other self-funded groups for whom the AIM Specialty Health® (AIM) Musculoskeletal Services Program is not applicable.
_________________________________________________

On 01/10/2019 the following 01/01/2019 CPT procedure codes were added to Attachment A.: 20932, 20933, 20934. These codes have become part of the Musculoskeletal Services utilization management program through AIM Specialty Health®.

Revisions From 00.01.66a:

03/01/2018

This version of the policy will become effective 03/01/2018.

The following new policy has been updated to communicate the Company’s delegation of precertification/preapproval of select interventional pain management procedures to AIM Specialty Health® (AIM).

Revsions From 00.01.66:

01/02/2018

Effective 10/05/2017 this policy has been updated to the new policy template format.

This version of the policy will become effective 01/02/2018.

The following new policy has been developed to communicate the Company’s delegation of precertification/preapproval of select spinal and joint surgeries to AIM Specialty Health® (AIM).

Policy section was updated on 11/02/2017 to further clarify instances of when AIM Specialty Health® Clinical Appropriateness Guidelines will be used during precertification/preapproval. The effective date of this policy remain as 01/02/2018.

The following procedure codes were removed from Attachment A of this policy (on 11/02/2017), and are not part of precertification/preapproval of musculoskeletal services with AIM Specialty Health® (AIM):

20974, 22586, 0164T, and 0165T.

Version Effective Date:

1/1/2026

Version Issued Date:

1/6/2026

Version Reissued Date: