Musculoskeletal Surgery and Interventional Pain Management Services

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In keeping with our commitment of promoting continuous quality improvement for services provided to our members, Highmark has entered into an agreement with eviCore healthcare (eviCore) to implement a musculoskeletal (MSK) surgery and interventional pain management (IPM) services prior authorization program.

eviCore performs utilization management for MSK surgical procedures and IPM services for Highmark's fully insured Commercial, Medicare Advantage, and Affordable Care Act members. Highmark manages prior authorizations for MSK surgeries or IPM services for all other members according to the member's benefits.

The MSK and IPM services program includes prior authorization for non-emergent MSK surgeries, including inpatient and outpatient lumbar, cervical, and thoracic spinal surgeries, and hip, knee, and shoulder surgeries and related procedures. Prior authorizations are required for outpatient IPM services such as spinal injections, spinal denervations, and stimulators or pain pumps.

Learn More About the MSK Surgery and IPM Program

eviCore's Website

You can access eviCore's Highmark implementation site linked below for the most current information. There you'll find eviCore's evidence-based clinical guidelines, a list of Current Procedural Terminology codes that require authorization through eviCore, and other important resources and recent announcements.

eviCore Highmark Provider Clinical Guidelines

Educational Materials/Communications

• How to Enter Multiple Procedure Codes
• Prior Authorization Provider Orientation
  • Presentation
• Other options available to you for updates about the MSK surgery and IPM services prior authorization program include the online provider portal and future issues of Provider News.

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Effective Aug. 1, 2024, Highmark New York requires prior authorization for inpatient and outpatient musculoskeletal (MSK) procedures. New and continuing authorization requirements for inpatient and outpatient MSK services are managed directly by Highmark New York.

These changes apply to Highmark New York members enrolled in our fully insured Commercial, Medicare Advantage, and Affordable Care Act (ACA) plans, as well as members of select self-insured (Administrative Services Only) groups.

Highmark’s List of Procedures/DME Requiring Authorization will be updated with CPT codes for MSK procedures, including the following services:

• Large joint surgeries
• Spine surgeries
• Interventional pain management procedures

Requesting Authorization for MSK Services

Authorization requests should be submitted through Availity, Highmark’s online provider portal. Once you log in to Availity, you will access the Predictal^TM Auth Automation Hub to request authorization for MSK procedures.

Authorization Requirements

For additional information and resources on submitting authorizations, go to the link below.

Authorization Guidance