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FLASH: eviCore Spine Surgery Clinical Criteria Update

Starting September 15, preauthorizations for spine surgery will no longer require documentation of patient-reported outcome measures, including the modified Japanese Orthopaedic Association (mJOA), Short Form Health Survey Score/Mental Component Summary (SF-36 MCS) or the Oswestry Disability Index (ODI).

Any cases currently in the appeal process that were denied based solely on these requirements will be overturned and approved.

We still recommend that providers identify and help patients with reasonably modifiable medical and behavioral health co-morbidities improve before elective spine surgery.

If you have any questions, contact your provider relations specialist.

Understanding eviCore’s Therapy Approval Letters

eviCore lists both the number of visits and the number of service units approved on the therapy approval letters sent to members and providers. Some providers have asked us how they should manage care based on units when their services are visit-based. We want you to know that we manage claims based on visits only, not units.

Even though we aren’t using them, we’ve decided to leave the units on the approval letters since some providers might use that information in internal processes.

If you have any questions, contact your provider relations specialist.

Eliminating Antiemetics Preauthorizations

Preauthorizations for antiemetics will no longer be required. When members need these drugs, we don’t want you to have to worry about getting a preauthorization from us first.

We have removed these codes from eviCore, so you can no longer try to get a preauthorization:

  • Akynzeo
  • Aloxi
  • Emend IV
  • Emend oral
  • Sustol

If you have any questions, contact your provider relations specialist.