Clover Health Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures prior authorization requirements (2026)
What Clover Health generally requires to approve Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (CPT 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267), for medicare_advantage plans. Yes. Clover Health generally requires prior authorization for Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (CPT 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267).
Medical-necessity criteria Clover Health generally applies
Prior authorization required via eviCore (CMM-608 lumbar / CMM-603 cervical decompression). Medicare note: open laminectomy/decompression has NO governing NCD/LCD — only the distinct percutaneous image-guided decompression (PILD, NCD 150.13) is restricted (non-covered except under Coverage with Evidence Development); it does not apply to open codes 63005-63048.
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures. Confirm the covered diagnosis list against the current Clover Health policy.
How to submit
- Method: eviCore portal
- Portal: eviCore (by Evernorth)
Sources & verification
- BindingSource — eviCore CMM-608 Lumbar Decompression (open laminectomy has no NCD; PILD NCD 150.13 is distinct) (CMM-608) · effective 2025-07-01.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 Clover Health require prior authorization for Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures?
Yes. Clover Health generally requires prior authorization for Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures (CPT 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267).
What does Clover Health require to approve Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures?
Prior authorization required via eviCore (CMM-608 lumbar / CMM-603 cervical decompression). Medicare note: open laminectomy/decompression has NO governing NCD/LCD — only the distinct percutaneous image-guided decompression (PILD, NCD 150.13) is restricted (non-covered except under Coverage with Evidence Development); it does not apply to open codes 63005-63048. 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 Cervical, Lumbar and Thoracic Laminectomy and/or Laminotomy Procedures 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.