Fidelis Care Lumbar Spinal Fusion prior authorization requirements (2026)
What Fidelis Care generally requires to approve Lumbar Spinal Fusion (CPT 22612), for Medicaid plans. Yes. Fidelis Care generally requires prior authorization for Lumbar Spinal Fusion (CPT 22612).
Medical-necessity criteria Fidelis Care generally applies
Lumbar spinal fusion requires prior authorization through NIA (National Imaging Associates), the Fidelis musculoskeletal review partner, with medical necessity determined under Centene clinical policy and nationally recognized MCG (Milliman Care Guidelines) criteria. Documentation should establish the standard medical-necessity elements: a clear surgical indication (e.g., instability, spondylolisthesis, or deformity), correlating imaging, and failed conservative management. Submit history and physical, imaging, and conservative-treatment records; verify the current MCG/Centene 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 Fidelis Care policy.
Source
Source: Fidelis Care Medicaid MSK (Hip/Knee/Shoulder/Spine) Surgery prior-authorization program via NIA/Evolent (radmd.com); medical necessity per Centene clinical policy and MCG. Last verified 2026-06-11.
Frequently asked questions
Does Fidelis Care require prior authorization for Lumbar Spinal Fusion?
Yes. Fidelis Care generally requires prior authorization for Lumbar Spinal Fusion (CPT 22612).
What does Fidelis Care require to approve Lumbar Spinal Fusion?
Lumbar spinal fusion requires prior authorization through NIA (National Imaging Associates), the Fidelis musculoskeletal review partner, with medical necessity determined under Centene clinical policy and nationally recognized MCG (Milliman Care Guidelines) criteria. Documentation should establish the standard medical-necessity elements: a clear surgical indication (e.g., instability, spondylolist… Always confirm against the current Fidelis Care policy.
How long does a Fidelis Care prior authorization take?
Turnaround varies by plan and submission method. Check the Fidelis Care portal for current timeframes.
Submitting Lumbar Spinal Fusion to Fidelis Care?
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.