Cigna prior authorization, page 9

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
21899*	Unlisted procedure, neck or thorax	Master Precertification List For Health Care Providers, Pg 23 Original policy
22207*	Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); lumbar	Master Precertification List For Health Care Providers, Pg 23 Original policy
22208*	Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment	Master Precertification List For Health Care Providers, Pg 23 Original policy
22210*	Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical	Master Precertification List For Health Care Providers, Pg 23 Original policy
22214*	Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar	Master Precertification List For Health Care Providers, Pg 23 Original policy
22216*	Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment	Master Precertification List For Health Care Providers, Pg 23 Original policy
22220*	Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical	Master Precertification List For Health Care Providers, Pg 23 Original policy
22224*	Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar	Master Precertification List For Health Care Providers, Pg 23 Original policy
22226*	Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment	Master Precertification List For Health Care Providers, Pg 23 Original policy
22505*	Manipulation of spine requiring anesthesia, any region	Master Precertification List For Health Care Providers, Pg 23 Original policy
22510*	Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic	Master Precertification List For Health Care Providers, Pg 24 Original policy
22511*	Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral	Master Precertification List For Health Care Providers, Pg 24 Original policy
22512*	Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body	Master Precertification List For Health Care Providers, Pg 24 Original policy
22513*	Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic	Master Precertification List For Health Care Providers, Pg 24 Original policy
22514*	Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar	Master Precertification List For Health Care Providers, Pg 24 Original policy
22515*	Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body	Master Precertification List For Health Care Providers, Pg 24 Original policy
22526*	Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level	Master Precertification List For Health Care Providers, Pg 24 Original policy
22527*	Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels	Master Precertification List For Health Care Providers, Pg 24 Original policy
22533*	Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar	Master Precertification List For Health Care Providers, Pg 24 Original policy
22534*	Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment	Master Precertification List For Health Care Providers, Pg 24 Original policy
22551*	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2	Master Precertification List For Health Care Providers, Pg 24 Original policy
22552*	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace	Master Precertification List For Health Care Providers, Pg 24 Original policy
22554*	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2	Master Precertification List For Health Care Providers, Pg 24 Original policy
22556*	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic	Master Precertification List For Health Care Providers, Pg 24 Original policy
22558*	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar	Master Precertification List For Health Care Providers, Pg 24 Original policy
22585*	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace	Master Precertification List For Health Care Providers, Pg 24 Original policy
22586*	Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace	Master Precertification List For Health Care Providers, Pg 24 Original policy
22595*	Arthrodesis, posterior technique, atlas-axis (C1-C2)	Master Precertification List For Health Care Providers, Pg 24 Original policy
22600*	Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment	Master Precertification List For Health Care Providers, Pg 24 Original policy
22610*	Arthrodesis, posterior or posterolateral technique, single interspace; thoracic (with lateral transverse technique, when performed)	Master Precertification List For Health Care Providers, Pg 24 Original policy
22612*	Arthrodesis, posterior or posterolateral technique, single interspace; lumbar (with lateral transverse technique, when performed)	Master Precertification List For Health Care Providers, Pg 25 Original policy
22614*	Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace	Master Precertification List For Health Care Providers, Pg 25 Original policy
22630*	Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar;	Master Precertification List For Health Care Providers, Pg 25 Original policy
22632*	Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar; each additional interspace	Master Precertification List For Health Care Providers, Pg 25 Original policy
22633*	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;	Master Precertification List For Health Care Providers, Pg 25 Original policy
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	Master Precertification List For Health Care Providers, Pg 25 Original policy
22800*	Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments	Master Precertification List For Health Care Providers, Pg 25 Original policy
22802*	Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments	Master Precertification List For Health Care Providers, Pg 25 Original policy
22804*	Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments	Master Precertification List For Health Care Providers, Pg 25 Original policy
22808*	Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments	Master Precertification List For Health Care Providers, Pg 25 Original policy
22810*	Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments	Master Precertification List For Health Care Providers, Pg 25 Original policy
22812*	Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments	Master Precertification List For Health Care Providers, Pg 25 Original policy
22836*	Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; up to 7 vertebral segments	Master Precertification List For Health Care Providers, Pg 25 Original policy
22837*	Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; 8 or more vertebral segments	Master Precertification List For Health Care Providers, Pg 25 Original policy
22838*	Revision (eg, augmentation, division of tether), replacement, or removal of thoracic vertebral body tethering, including thoracoscopy, when performed	Master Precertification List For Health Care Providers, Pg 25 Original policy
22840*	Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation)	Master Precertification List For Health Care Providers, Pg 25 Original policy
22841*	Internal spinal fixation by wiring of spinous processes	Master Precertification List For Health Care Providers, Pg 25 Original policy
22842*	Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments	Master Precertification List For Health Care Providers, Pg 25 Original policy
22843*	Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments	Master Precertification List For Health Care Providers, Pg 25 Original policy
22844*	Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments	Master Precertification List For Health Care Providers, Pg 25 Original policy

Removed codes

Cigna codes removed from the master precertification list

Sources

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