AIM (out-of-state / Federal BCBS) Artificial Intervertebral Disc Surgery (Lumbar Spine) prior authorization requirements (2026)
What AIM (out-of-state / Federal BCBS) generally requires to approve Artificial Intervertebral Disc Surgery (Lumbar Spine) (CPT 22857, 22860, 22862, 22865), for commercial plans. Yes. AIM (out-of-state / Federal BCBS) generally requires prior authorization for Artificial Intervertebral Disc Surgery (Lumbar Spine) (CPT 22857, 22860, 22862, 22865).
Medical-necessity criteria AIM (out-of-state / Federal BCBS) generally applies
Prior authorization via Carelon (Spine Surgery MSK03). Age 18-60; discogenic axial pain; symptoms at least 6 months unresponsive to conservative care; single or dual (2-level FDA device) level at L3-L4, L4-L5, or L5-S1 with moderate-to-severe degeneration plus Modic changes; VAS at least 40/100; no DDD at other lumbar levels. Contraindications: significant facet arthropathy, bony stenosis, pars defect, prior fusion at level, spondylolisthesis grade over 1, infection/tumor, osteopenia/osteoporosis (DEXA T-score at or below -1.0), chronic radiculopathy (leg over back pain for over 1 year). Excluded: more than one level (unless an FDA-approved multilevel device), prior lumbar fusion, isolated radicular/herniation cases, hybrid.
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Artificial Intervertebral Disc Surgery (Lumbar Spine). Confirm the covered diagnosis list against the current AIM (out-of-state / Federal BCBS) policy.
How to submit
- Method: Carelon ProviderPortal
- Portal: Carelon Medical Benefits Management
Sources & verification
- BindingSource — Carelon Clinical Appropriateness Guidelines — Spine Surgery (MSK03-1125.1-UC0126) · effective 2026-01-01.View
Binding = the payer's own policy. Proxy = a public, evidence-based clinical guideline the payer mirrors. Portal-only = the binding criteria are confirmed in the administrator's portal. Always confirm against the payer for the member's specific plan. Last verified 2026-06-26.
Frequently asked questions
Does AIM (out-of-state / Federal BCBS) require prior authorization for Artificial Intervertebral Disc Surgery (Lumbar Spine)?
Yes. AIM (out-of-state / Federal BCBS) generally requires prior authorization for Artificial Intervertebral Disc Surgery (Lumbar Spine) (CPT 22857, 22860, 22862, 22865).
What does AIM (out-of-state / Federal BCBS) require to approve Artificial Intervertebral Disc Surgery (Lumbar Spine)?
Prior authorization via Carelon (Spine Surgery MSK03). Age 18-60; discogenic axial pain; symptoms at least 6 months unresponsive to conservative care; single or dual (2-level FDA device) level at L3-L4, L4-L5, or L5-S1 with moderate-to-severe degeneration plus Modic changes; VAS at least 40/100; no DDD at other lumbar levels. Contraindications: significant facet arthropathy, bony stenosis, pars de… Always confirm against the current AIM (out-of-state / Federal BCBS) policy.
How long does a AIM (out-of-state / Federal BCBS) prior authorization take?
Turnaround varies by plan and submission method. Check the AIM (out-of-state / Federal BCBS) portal for current timeframes.
Submitting Artificial Intervertebral Disc Surgery (Lumbar Spine) to AIM (out-of-state / Federal BCBS)?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.