Does Anthem require prior authorization for CPT 22630?

Yes. Anthem requires prior authorization for CPT 22630 (Spinal surgery procedures) under Standard commercial plans per its published clinical policy.

What documentation does Anthem require for CPT 22630?

Spinal imaging; Conservative treatment documentation; PT records; Neurological exam; Surgical plan with level specification

How much does Medicare pay for CPT 22630 in 2026?

In 2026, the national Medicare allowable for CPT 22630 is $1510.72 in an office setting and $1510.72 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.

What if Anthem denies the PA for CPT 22630?

Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Prior Authorization

Anthem Prior Authorization for CPT 22630

Spinal surgery procedures · Standard commercial plans

Prior authorization REQUIREDApplies to all statesLast verified January 1, 2026 · Reviewed by the D3rx Clinical Billing Team

Source

Anthem clinical policy

Not medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.

Clinical criteria

Anthem requires prior authorization for lumbar spinal fusion. Must document structural pathology on imaging concordant with symptoms, 3+ months of failed conservative therapy, and functional limitation. Single-level DDD with instability, spondylolisthesis, and recurrent herniation are standard indications. Interspinous process devices are investigational for most indications.

Documentation checklist

✓Spinal imaging
✓Conservative treatment documentation
✓PT records
✓Neurological exam
✓Surgical plan with level specification

Submission channels

Phone

1-800-274-7767

2026 Medicare rate for CPT 22630

Office (non-facility)

$1510.72

Facility

$1510.72

Total RVUs (office)

45.23

Conversion factor

$33.4009

National Medicare Physician Fee Schedule amounts (GPCI 1.0). Anthem's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 22630 code page.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather documentation: Spinal imaging, Conservative treatment documentation, PT records….
3Submit via phone, or the payer portal.
4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Anthem require prior authorization for CPT 22630?: Yes. Anthem requires prior authorization for CPT 22630 (Spinal surgery procedures) under Standard commercial plans per its published clinical policy.
What documentation does Anthem require for CPT 22630?: Spinal imaging; Conservative treatment documentation; PT records; Neurological exam; Surgical plan with level specification
How much does Medicare pay for CPT 22630 in 2026?: In 2026, the national Medicare allowable for CPT 22630 is $1510.72 in an office setting and $1510.72 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.
What if Anthem denies the PA for CPT 22630?: Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Other Anthem PA lookups

CPT 17110 CPT 45380 CPT 45378 CPT 11042 CPT 36415 CPT 20610 CPT 62323 CPT 43235

All Anthem prior-authorization requirements →

CPT 22630 prior authorization by payer

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