Cigna prior authorization, page 20

Requirements

Read the care-management columns separately. Complete, PHS+, Preferred, and Basic Standard do not collapse into one Cigna answer. The long descriptor is blank because no AMA-licensed CPT file was available to copy.

Cigna precertification list

Cigna master precertification list

Cigna precertification

CPT code lookup

Prior authorization codes

Prior authorization codes
Code	Description	Source
62263*	Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days	Master Precertification List For Health Care Providers, Pg 49 Original policy
62264*	Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day	Master Precertification List For Health Care Providers, Pg 49 Original policy
62280*	Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid	Master Precertification List For Health Care Providers, Pg 49 Original policy
62281*	Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic	Master Precertification List For Health Care Providers, Pg 49 Original policy
62282*	Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal)	Master Precertification List For Health Care Providers, Pg 49 Original policy
62287*	Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar	Master Precertification List For Health Care Providers, Pg 49 Original policy
62290*	Injection procedure for discography, each level; lumbar	Master Precertification List For Health Care Providers, Pg 49 Original policy
62320*	Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance	Master Precertification List For Health Care Providers, Pg 49 Original policy
62321*	Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)	Master Precertification List For Health Care Providers, Pg 49 Original policy
62322*	Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance	Master Precertification List For Health Care Providers, Pg 49 Original policy
62323*	Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)	Master Precertification List For Health Care Providers, Pg 49 Original policy
62324*	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance	Master Precertification List For Health Care Providers, Pg 50 Original policy
62325*	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)	Master Precertification List For Health Care Providers, Pg 50 Original policy
62327*	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)	Master Precertification List For Health Care Providers, Pg 50 Original policy
62350*	Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy	Master Precertification List For Health Care Providers, Pg 50 Original policy
62351*	Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy	Master Precertification List For Health Care Providers, Pg 50 Original policy
62360*	Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir	Master Precertification List For Health Care Providers, Pg 50 Original policy
62361*	Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump	Master Precertification List For Health Care Providers, Pg 50 Original policy
62362*	Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming	Master Precertification List For Health Care Providers, Pg 50 Original policy
62380*	Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar	Master Precertification List For Health Care Providers, Pg 50 Original policy
63001*	Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical	Master Precertification List For Health Care Providers, Pg 50 Original policy
63005*	Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis	Master Precertification List For Health Care Providers, Pg 50 Original policy
63012*	Laminectomy with removal of abnormal facets and/or pars inter- articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)	Master Precertification List For Health Care Providers, Pg 50 Original policy
63015*	Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; cervical	Master Precertification List For Health Care Providers, Pg 50 Original policy
63016*	Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; thoracic	Master Precertification List For Health Care Providers, Pg 50 Original policy
63017*	Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar	Master Precertification List For Health Care Providers, Pg 50 Original policy
63020*	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical	Master Precertification List For Health Care Providers, Pg 50 Original policy
63030*	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar	Master Precertification List For Health Care Providers, Pg 50 Original policy
63042*	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar	Master Precertification List For Health Care Providers, Pg 51 Original policy
63044*	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace	Master Precertification List For Health Care Providers, Pg 51 Original policy
63045*	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical	Master Precertification List For Health Care Providers, Pg 51 Original policy
63047*	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar	Master Precertification List For Health Care Providers, Pg 51 Original policy
63048*	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional vertebral segment, cervical, thoracic, or lumbar	Master Precertification List For Health Care Providers, Pg 51 Original policy
63056*	Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)	Master Precertification List For Health Care Providers, Pg 51 Original policy
63057*	Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar	Master Precertification List For Health Care Providers, Pg 51 Original policy
63077*	Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, single interspace	Master Precertification List For Health Care Providers, Pg 51 Original policy
63078*	Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, each additional interspace	Master Precertification List For Health Care Providers, Pg 51 Original policy
63081*	Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment	Master Precertification List For Health Care Providers, Pg 51 Original policy
63082*	Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment	Master Precertification List For Health Care Providers, Pg 51 Original policy
63087*	Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment	Master Precertification List For Health Care Providers, Pg 51 Original policy
63088*	Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; each additional segment	Master Precertification List For Health Care Providers, Pg 51 Original policy
63090*	Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment	Master Precertification List For Health Care Providers, Pg 51 Original policy
63091*	Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment	Master Precertification List For Health Care Providers, Pg 51 Original policy
63267*	Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar	Master Precertification List For Health Care Providers, Pg 51 Original policy
63620*	Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion	Master Precertification List For Health Care Providers, Pg 51 Original policy
63621*	Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion	Master Precertification List For Health Care Providers, Pg 51 Original policy
63650*	Percutaneous implantation of neurostimulator electrode array, epidural	Master Precertification List For Health Care Providers, Pg 51 Original policy
63655*	Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural	Master Precertification List For Health Care Providers, Pg 51 Original policy
63685*	Insertion or replacement of spinal neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver	Master Precertification List For Health Care Providers, Pg 52 Original policy
64451*	Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)	Master Precertification List For Health Care Providers, Pg 52 Original policy

Removed codes

Cigna codes removed from the master precertification list

Sources

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