Skip to Main Content

MSK Announcement

Effective April 1, 2024, these additional procedure codes will require prior authorization for outpatient settings:
CPTDescription
22533ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESS)
22858Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)
23120CLAVICULECTOMY; PARTIAL
23125CLAVICULECTOMY; TOTAL
23130ACROMIOPLASTY OR ACROMIONECTOMY, PARTIAL, WITH OR WITHOUT CORACOACROMIAL LIGAMENT RELEASE
23450CAPSULORRHAPHY, ANTERIOR; PUTTI-PLATT PROCEDURE OR MAGNUSON TYPE OPERATION
23455CAPSULORRHAPHY, ANTERIOR; WITH LABRAL REPAIR (EG, BANKART PROCEDURE)
23460CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK
23462CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH CORACOID PROCESS TRANSFER
23465CAPSULORRHAPHY, GLENOHUMERAL JOINT, POSTERIOR, WITH OR WITHOUT BONE BLOCK
23466CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTI-DIRECTIONAL INSTABILITY
23700MANIPULATION UNDER ANESTHESIA, SHOULDER JOINT, INCLUDING APPLICATION OF FIXATION APPARATUS (DISLOCATION EXCLUDED)
27132CONVERSION OF PREVIOUS HIP SURGERY TO TOTAL HIP ARTHROPLASTY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT
27134REVISION OF TOTAL HIP ARTHROPLASTY; BOTH COMPONENTS, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT
27137REVISION OF TOTAL HIP ARTHROPLASTY; ACETABULAR COMPONENT ONLY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT
27138REVISION OF TOTAL HIP ARTHROPLASTY; FEMORAL COMPONENT ONLY, WITH OR WITHOUT ALLOGRAFT
27279Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device
27416OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S])
27418ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)
27420RECONSTRUCTION OF DISLOCATING PATELLA; (EG, HAUSER TYPE PROCEDURE)
27422RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDW
27424RECONSTRUCTION OF DISLOCATING PATELLA; WITH PATELLECTOMY
27425LATERAL RETINACULAR RELEASE, OPEN
27570MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES)
29807Arthroscopy, shoulder, surgical; repair of SLAP lesion
29819Arthroscopy, shoulder, surgical; with removal of loose body or foreign body
63050LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL CORD, TWO OR MORE VERTEBRAL SEGMENTS;
63051LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL CORD, TWO OR MORE VERTEBRAL SEGMENTS; WITH RECONSTRUCTION OF THE
63661REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED
63662REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERF
 

MSK surgeries other than those outlined above will continue to follow Wellcare prior authorization requirements for hospital admissions and elective surgeries.