Fallon Health Lumbar Spinal Fusion prior authorization requirements (2026)
What Fallon Health generally requires to approve Lumbar Spinal Fusion (CPT 22612), for Commercial, MassHealth ACO (Fallon 365 Care), Medicare plans. Yes. Fallon Health generally requires prior authorization for Lumbar Spinal Fusion (CPT 22612).
Medical-necessity criteria Fallon Health generally applies
Prior authorization is required for all elective inpatient admissions and for facility/same-day surgery and ambulatory procedures listed on the Fallon procedure-codes list; lumbar fusion falls within these categories. Reviewed against InterQual / Fallon medical policy.
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Lumbar Spinal Fusion. Confirm the covered diagnosis list against the current Fallon Health policy.
Commonly required documentation
- Office notes, imaging, and conservative-care documentation supporting medical necessity.
How to submit
- Method: Fallon provider portal (PA fax 508-368-9700)
- Portal: Fallon Health
Source
Source: Fallon Referral and Prior Authorization Procedures. Confirm CPT 22612 on the Fallon procedure-codes list. Last verified 2026-06-17.
Frequently asked questions
Does Fallon Health require prior authorization for Lumbar Spinal Fusion?
Yes. Fallon Health generally requires prior authorization for Lumbar Spinal Fusion (CPT 22612).
What does Fallon Health require to approve Lumbar Spinal Fusion?
Prior authorization is required for all elective inpatient admissions and for facility/same-day surgery and ambulatory procedures listed on the Fallon procedure-codes list; lumbar fusion falls within these categories. Reviewed against InterQual / Fallon medical policy. Always confirm against the current Fallon Health policy.
How long does a Fallon Health prior authorization take?
Turnaround varies by plan and submission method. Check the Fallon Health portal for current timeframes.
Submitting Lumbar Spinal Fusion to Fallon 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.