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Ambetter from Managed Health Services (Ambetter) Utilization Review Matrix 2023 Outpatient Interventional Pain Management (IPM)
Date: 03/09/23
The matrix below contains all of the CPT 4 codes for which National Imaging Associates Inc. (NIA) authorizes on behalf of Ambetter.
NIA issues authorizations based on the primary CPT code and its allowable billed groupings. A procedure can be billed under any one of the given CPT codes for that allowable billed grouping as long as a valid authorization number has been issued within the validity period.
*Please note: IPM services rendered in an Emergency Room, Observation Room, Intraoperatively, or as a Hospital Inpatient are not managed by NIA.
Procedure Name | Primary CPT Code | Allowable Billed Groupings |
|---|---|---|
Sacroiliac Joint Injection | 27096 | 27096, G0260 |
Cervical/Thoracic Interlaminar Epidural | 62321 | 62320, 62321 |
Cervical/Thoracic Transforaminal Epidural | 64479 | 64479, +64480 |
Lumbar/Sacral Interlaminar Epidural | 62323 | 62322, 62323 |
Lumbar/Sacral Transforaminal Epidural | 64483 | 62322, 62323 |
Cervical/Thoracic Facet Joint Block | 64490 | 64490, + 64491, +64492, 0213T, +0214T, +0215T |
| Lumbar/Sacral Facet Joint Block | 64493 | 64493, +64494, +64495, 0216T, +0217T, +0218T |
Cervical/Thoracic Facet Joint Radiofrequency Neurolysis | 64633 | 64633, +64634 |
Lumbar/Sacral Facet Joint Radiofrequency Neurolysis | 64635 | 64635, +64636 |
Sympathetic Nerve Block | 64510 | 64510, 64517, 64520, 64530 |
- Add-on codes (+) do not require separate authorization and are to be used in conjunction with approved primary code for the service rendered.
- NOTE: due the repeat nature of IPM procedures, multiple authorizations may exist within the same validity period.