Prior Authorization
Humana Prior Authorization for CPT 22630
Spinal surgery procedures · Standard commercial plans
Source
Humana Commercial Preauthorization and Notification List (July 2024)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
Humana requires prior authorization for lumbar spinal fusion. Must demonstrate structural instability or deformity on imaging, 12+ weeks of failed conservative therapy, concordant neurological findings, and documented functional impairment. Fusion for isolated axial back pain without instability does not meet criteria. Smoking cessation documentation may be required.
Documentation checklist
- ✓MRI/CT spine
- ✓Conservative treatment records (12+ weeks)
- ✓PT documentation
- ✓Neurological exam
- ✓Surgical plan
Submission channels
Phone
1-800-444-9137Fax
1-877-418-05062026 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). Humana'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: MRI/CT spine, Conservative treatment records (12+ weeks), PT documentation….
- 3Submit via phone or fax, or the payer portal.
- 4Document the reference number and follow up within 5 business days if no determination is received.
FAQ
- Does Humana require prior authorization for CPT 22630?
- Yes. Humana requires prior authorization for CPT 22630 (Spinal surgery procedures) under Standard commercial plans per its published clinical policy.
- What documentation does Humana require for CPT 22630?
- MRI/CT spine; Conservative treatment records (12+ weeks); PT documentation; Neurological exam; Surgical plan
- 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 Humana are typically negotiated against this benchmark.
- What if Humana 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 Humana PA lookups
CPT 22630 prior authorization by payer
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