WellSense Health Plan Lumbar Spinal Fusion prior authorization requirements (2026)
What WellSense Health Plan generally requires to approve Lumbar Spinal Fusion (CPT 22612), for MassHealth, Individual/ConnectorCare, Medicare plans. Yes. WellSense Health Plan generally requires prior authorization for Lumbar Spinal Fusion (CPT 22612).
Medical-necessity criteria WellSense Health Plan generally applies
Prior authorization required; delegated to eviCore (musculoskeletal spine program). CPT 22612 is listed verbatim on the WellSense eviCore Spine Surgery code list (effective 2026-01-01). Reviewed against eviCore MSK spine clinical guidelines.
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 WellSense Health Plan policy.
Related procedure codes
Codes often billed alongside Lumbar Spinal Fusion: 22612. Verify the correct codes for your documentation.
Commonly required documentation
- Office notes, imaging, and conservative-care documentation per eviCore spine criteria.
How to submit
- Method: eviCore (844-725-4448 prompt 3, fax 855-774-1319)
- Portal: eviCore healthcare
Source
Source: WellSense eviCore Spine CPT list eff 01/01/2026; WellSense 2026 MA Provider Manual. Last verified 2026-06-17.
Frequently asked questions
Does WellSense Health Plan require prior authorization for Lumbar Spinal Fusion?
Yes. WellSense Health Plan generally requires prior authorization for Lumbar Spinal Fusion (CPT 22612).
What does WellSense Health Plan require to approve Lumbar Spinal Fusion?
Prior authorization required; delegated to eviCore (musculoskeletal spine program). CPT 22612 is listed verbatim on the WellSense eviCore Spine Surgery code list (effective 2026-01-01). Reviewed against eviCore MSK spine clinical guidelines. Always confirm against the current WellSense Health Plan policy.
How long does a WellSense Health Plan prior authorization take?
Turnaround varies by plan and submission method. Check the WellSense Health Plan portal for current timeframes.
Submitting Lumbar Spinal Fusion to WellSense Health Plan?
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.