Musculoskeletal Surgery and Interventional Pain Management Services

Highmark requires prior authorization for inpatient and outpatient musculoskeletal (MSK) and interventional pain management (IPM) procedures. New and continuing authorization requirements for inpatient and outpatient MSK and IPM services are managed directly by Highmark.

These requirements apply to Highmark 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.

MSK procedures that require authorization include the following:

• Large joint surgeries
• Spine surgeries

Prior Authorization Coding

The procedure codes contained in the lists below usually require authorization (based on the member’s benefit plan/eligibility). Effective dates are subject to change. Highmark will provide written notice when codes are added to the list; deletions are announced via online publication.

• View the List of Procedures/DME Requiring Authorization 
  • This is not an all-inclusive list. Benefits can vary; always confirm member coverage.

Requesting Authorization for MSK Services

Authorization requests should be submitted through Availity Essentials, Highmark’s online provider portal.

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

• Authorization Guidance