Clover Health Artificial Intervertebral Disc Surgery (Lumbar Spine) prior authorization requirements (2026)
What Clover Health generally requires to approve Artificial Intervertebral Disc Surgery (Lumbar Spine) (CPT 22857, 22860, 22862, 22865), for medicare_advantage plans. Yes. Clover Health generally requires prior authorization for Artificial Intervertebral Disc Surgery (Lumbar Spine) (CPT 22857, 22860, 22862, 22865).
Medical-necessity criteria Clover Health generally applies
NON-COVERED for Medicare beneficiaries over age 60 (CMS NCD 150.10). For beneficiaries age 60 or younger there is no NCD, so coverage follows the local MAC/LCD and eviCore CMM-610 criteria (single-level L3-S1, FDA-approved disc, no hybrid fusion). Submit via eviCore.
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 Clover Health policy.
How to submit
- Method: eviCore portal
- Portal: eviCore (by Evernorth)
Sources & verification
- BindingSource — CMS NCD 150.10 — Lumbar Artificial Disc Replacement (non-covered over age 60) (NCD 150.10) · effective 2007-08-14.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 Clover Health require prior authorization for Artificial Intervertebral Disc Surgery (Lumbar Spine)?
Yes. Clover Health generally requires prior authorization for Artificial Intervertebral Disc Surgery (Lumbar Spine) (CPT 22857, 22860, 22862, 22865).
What does Clover Health require to approve Artificial Intervertebral Disc Surgery (Lumbar Spine)?
NON-COVERED for Medicare beneficiaries over age 60 (CMS NCD 150.10). For beneficiaries age 60 or younger there is no NCD, so coverage follows the local MAC/LCD and eviCore CMM-610 criteria (single-level L3-S1, FDA-approved disc, no hybrid fusion). Submit via eviCore. Always confirm against the current Clover Health policy.
How long does a Clover Health prior authorization take?
Turnaround varies by plan and submission method. Check the Clover Health portal for current timeframes.
Submitting Artificial Intervertebral Disc Surgery (Lumbar Spine) to Clover Health?
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.