Prior Approval Requirement for Spinal Surgeries Delayed

Session Law 2011-145 HB 200 Section 10.37(a)(11)(g)(4) required the Division of Medical Assisstance (DMA) to implement prior approval (PA) for spinal surgery for selective diagnoses and require that all other therapies have been exhausted prior to granting approval. Currently, only cervical laminoplasty (CPT Codes 63050 and 63051) requires prior approval.

In the April 2017 Medicaid Bulletin article, New Coverage and Prior Approval Requirements for Spinal Surgeries, an implementation date of July 1, 2017, was announced. However, the implementation has been delayed. Until the change is implemented, PA will not be required for spinal surgeries apart from CPT codes 63050 and 63051. DMA will provide updates through future Medicaid Bulletin articles and provider notifications in NCTracks.

Please refer to the April 2017 Medicaid Bulletin for information regarding which surgical procedures will require PA as well as which diagnoses are exempt from prior approval.