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Minimally Invasive Spine Surgery Procedures and Trigger ...

Page 1 of 46 Medical Coverage Policy: 0139 Medical Coverage Policy Effective Date .. 7/15/2021 Next Review Date .. 7/15/2022 Coverage Policy Number .. 0139 Minimally Invasive Spine Surgery Procedures and Trigger Point Injections Table of Contents Overview .. 1 Coverage Policy .. 2 General Background .. 4 Medicare Coverage Determinations .. 27 Coding/Billing Information .. 27 References .. 32 Related Coverage Resources Acupuncture bone , Cartilage and Ligament Graft Substitutes Botulinum Therapy Cervical Fusion Discography Intervertebral Disc (IVD) Prostheses Lumbar Fusion for Spinal Instability and Degenerative Disc Conditions, Including Sacroiliac Fusion Mechanical Devices for the Treatment of Back Pain Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty Orthotic Devices and Shoes INSTRUCTIONS FOR USE Th

intradiscal injections (e.g., methylene blue, platelet rich plasma, mesenchymal stem cells, bone marrow concentrate, tumor necrosis factor [TNF] alpha), gelified ethanol [e.g., DiscoGel®], and/or paravertebral oxygen/ozone injection) (CPT codes 0627T, 0628T, 0629T, 0630T)

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This Coverage Policy addresses bariatric surgery and procedures for the treatment of morbid obesity. Coverage Policy . Coverage for bariatric surgery or revision of a bariatric surgery procedure varies across plans and may be governed by state mandates. Refer to the customer’s benefit plan document for coverage details.

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