GoHealthcare Knowledge Center | Orthopedic Surgery

Orthopedic Prior Authorization

Medicare, Medicare Advantage, commercial payer, delegated utilization management, medical necessity, peer-to-peer, denial prevention, and appeal operations.

Developed by Pinky Maniri, MSc, CRCR, CSAPM, CSPPM, CSBI, CSPR, CSAF, Certified in Healthcare A.I. Governance | Founder and Chief Executive Officer, GoHealthcare Practice Solutions

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Important Notice This page is an educational and operational reference. It is not a surgical technique manual, a substitute for physician clinical judgment, coding advice for a specific claim, or legal advice. Coverage, authorization, coding, and payment requirements vary by payer, product line, state, contract, and date of service. Verify all requirements before reliance.

Orthopedic prior authorization requires correct routing, criteria fluency, complete evidence, precise approval capture, and disciplined reconciliation. This page separates Original Medicare, Medicare Advantage, commercial, delegated vendor, Medicaid, and workers' compensation pathways and translates them into an executable workflow.

Specialty Orthopedic Surgery

Focus Operations, payer policy, documentation, coding, compliance, and performance

Audience Physicians, APPs, administrators, PA/UM, RCM, ASCs, hospitals, and executives

Verification Standard Confirm current payer, CMS, coding, contractual, and state requirements

Page Contents

Prior Authorization Payer and Compliance Considerations Operational Case Study Frequently Asked Questions Authoritative References

Orthopedic Specialty Center

Orthopedic Surgery Specialty Guide Executive entry point for orthopedic service-line operations and the complete Orthopedic Surgery Specialty Hub. Orthopedic Practice Operations Operating model, scheduling, site-of-service, staffing, and pre-surgical huddle controls. Orthopedic Prior Authorization Decision pathways, payer criteria, authorization workflow, peer-to-peer, and appeals. Orthopedic Revenue Cycle Management Revenue leakage controls, financial clearance, payment changes, and RCM performance. Orthopedic Documentation Requirements Clinical documentation checklists for authorization, coding, payment, and audit defense. Orthopedic Coding and Billing Fundamentals CPT families, diagnosis coding, modifiers, place of service, and coding risk. Orthopedic Compliance and Audit Readiness Federal and payer compliance, audit risk, governance, and corrective controls. Orthopedic KPIs and Performance Management Definitions, owners, thresholds, and interventions for orthopedic performance metrics. AI Governance in Orthopedic Practices AI use cases, governance requirements, payer-side AI, and human accountability. Orthopedic Best Practices and Common Mistakes Best practices, common mistakes, operational pearls, pitfalls, and takeaways. Orthopedic Procedure Library Procedure categories and links across the GoHealthcare MSK Specialty Procedure Library. Orthopedic Surgery FAQs Twenty-five substantive orthopedic operations, payer, documentation, coding, and billing FAQs.

Prior Authorization

Prior authorization is where orthopedic operational competence is decided. The specialty carries an unusually heavy authorization burden because its highest-volume procedures are elective, expensive, implant-intensive, and supported by an evidence base that payers regard as variable. This section describes the authorization landscape, the entities that actually make the decisions, the criteria architecture that repeats across them, and the workflow that produces first-pass approvals.

Who actually decides

A recurring source of avoidable delay is submitting to the wrong decision-maker. In orthopedic surgery there are five distinct decision pathways, and the correct pathway is a function of the patient's product line, the state, and the plan's delegation arrangements rather than of the procedure itself.

Pathway	Who decides	What governs the decision	Practical notes
Original Medicare, standard	The Medicare Administrative Contractor, on a post-service basis	National Coverage Determinations, Local Coverage Determinations, Local Coverage Articles, and the Medicare manuals	Historically no prior authorization for most orthopedic surgery; coverage is adjudicated at the claim, which shifts the entire burden onto documentation
Original Medicare, WISeR states	A CMS model participant, or the Medicare Administrative Contractor for routing	The same NCDs and LCDs; the model does not create new coverage or documentation standards	Applies to Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington for included categories. For hospital outpatient department and ASC claims, the unique tracking number must appear on the facility claim or the claim is suspended for medical review. Associated services follow the primary service determination
Medicare Advantage	The plan, or a delegated utilization management vendor	Medicare coverage rules as a floor, plus internal coverage criteria where Medicare criteria are not fully established	Operational provisions effective January 1, 2026 set 72-hour expedited and 7-calendar-day standard decision timeframes and require a specific denial reason
Commercial and exchange	The plan, or a delegated vendor such as eviCore or Carelon	Plan medical policy and vendor clinical appropriateness guidelines	Vendor guidelines are published and versioned; plan policy can take precedence over vendor guidelines, and state mandates take precedence over both
Medicaid, managed Medicaid, workers' compensation, and other	The state agency, the managed care organization, or the compensation carrier	State Medicaid policy, state fee schedules, treatment guidelines, and utilization review statutes	Workers' compensation frequently applies its own treatment guidelines and its own independent medical review process on entirely separate timelines

Denial Risk

The most common structural error in orthopedic authorization is treating 'the payer' as one entity. A single commercial carrier may delegate joint surgery to one vendor, spine surgery to another, advanced imaging to a third, and physical therapy to a fourth, with different portals, different clinical criteria, different turnaround commitments, and different appeal pathways. Maintain a payer-and-product matrix that names the delegated entity for each service family, and re-verify it at least quarterly and at every contract renewal.

The delegated vendor landscape in musculoskeletal surgery

Two vendors carry the majority of delegated orthopedic surgical review volume.

eviCore by Evernorth

eviCore administers musculoskeletal benefits for a large number of health plans through its Comprehensive Musculoskeletal Management program. The program is organized into a pain management component covering epidural steroid injections, facet joint injections and medial branch blocks, radiofrequency ablation, sympathetic blocks, spinal cord stimulation, and implantable drug pumps; and a surgical component covering joint surgery of the hip, knee, and shoulder, including primary and revision arthroplasty and arthroscopic and open procedures, together with spinal surgery. Guidelines are published as numbered CMM documents, for example the knee surgery guideline addressing arthroscopic and open procedures. eviCore states that its guidelines undergo a formal annual review and that it reserves the right to change and update them without prior notice, and that health plan requirements or applicable state or federal regulatory policies may take precedence over its guidelines.

Website: https://www.evicore.com/provider/clinical-guidelines

Carelon Medical Benefits Management

Carelon publishes dated musculoskeletal clinical appropriateness guidelines and maintains both an archive of superseded versions and a preview of upcoming changes. As of the publication date of this guide, the current musculoskeletal set includes Joint Surgery, Small Joint Surgery, Spine Surgery, Sacroiliac Joint Fusion, Level of Care for Surgical Procedures, Site of Care for Surgical Procedures, and Interventional Pain Management, with several plan-specific versions maintained in parallel. Carelon states that its guidelines do not address coverage or benefit questions, that applicable federal and state coverage mandates take precedence, and that it will review against health plan medical policy in lieu of its own guidelines when a plan requests it.

Carelon musculoskeletal guideline	Version identified at publication date
Joint Surgery	2025-11-15
Small Joint Surgery	2025-11-15
Level of Care for Surgical Procedures	2025-11-15
Site of Care for Surgical Procedures	2024-11-17
Sacroiliac Joint Fusion	2025-11-15, updated 2026-01-01
Spine Surgery	2025-11-15, updated 2026-01-01
Interventional Pain Management	2026-06-14

Website: https://guidelines.carelonmedicalbenefitsmanagement.com/current-musculoskeletal-guidelines/

Policy Watch

Carelon separately publishes a plan-specific parallel track, including guidelines designated for particular Anthem product lines. Confirm which version applies to the specific member's plan before building a request. Submitting against the wrong version of the right vendor's guideline is a silent failure: the criteria appear correct, the packet appears complete, and the case still non-affirms.

Other entities

• Cohere Health and Evolent Health administer musculoskeletal and surgical utilization management for specific plans and regions, generally with a heavier emphasis on episode-level and pathway-level authorization rather than single-procedure review.
• TurningPoint Healthcare Solutions administers musculoskeletal and surgical quality programs for certain plans, frequently including implant and device-level review.
• NaviNet is a multi-payer provider workflow portal rather than a review entity; it is where submission and status tracking occur for a number of plans, and portal familiarity is an operational competency in its own right.

The criteria architecture that repeats across payers

Although the specific thresholds differ, almost every orthopedic surgical criteria set is constructed from the same seven elements. A prior authorization team that learns to assemble evidence for these seven elements can adapt to any new vendor or plan quickly.

Element	What the reviewer is looking for	How it fails
Diagnosis specificity	A specific, billable diagnosis that matches the imaging and the examination, not a symptom code and not an unspecified code	Non-billable parent codes and unspecified codes are submitted; the request is reviewed against a condition the patient may not have
Symptom duration	A stated duration of symptoms with an onset reference, meeting the guideline minimum	The chart says 'chronic' or 'long-standing' without a date anchor
Functional impairment	Objective, activity-referenced limitation, ideally with a validated instrument score, not an adjective	'Significant pain' and 'limited function' without any measure, comparator, or activity reference
Failed conservative therapy	Named modalities, start and end dates, duration, and the documented response or failure of each	Therapy is listed without dates; or it occurred outside the payer's look-back window; or it is described as 'recommended' rather than completed
Imaging correlation	Imaging that both exists and is interpreted in the clinical note in terms that support the specific procedure requested	The report is attached but never interpreted by the surgeon; or the findings are inconsistent with the requested procedure
Examination findings	Procedure-relevant physical findings, including provocative testing where the guideline references it, and range of motion where relevant	Templated normal examination that contradicts the stated severity
Absence of contraindication and alternative	An affirmative statement that contraindications were considered and that less invasive alternatives were considered and are not appropriate	Never documented at all; the reviewer is left to infer it and defaults to non-affirmation

GoHealthcare Insight

The conservative therapy element is the fulcrum of the entire specialty. In GoHealthcare's experience supporting musculoskeletal practices, the majority of orthopedic non-affirmations that are ultimately overturned on appeal were overturned not because new treatment was delivered but because existing treatment was finally documented in a form the reviewer could accept: named modality, start date, end date, frequency, and outcome. The care had already happened. The record simply did not say so in the reviewer's language. This is why GoHealthcare recommends a structured conservative-care ledger maintained in the chart from the first visit, rather than a retrospective reconstruction assembled at the moment of the authorization request.

The GoHealthcare authorization workflow

1. Verify the pathway. Confirm plan, product line, and delegated vendor before assembling anything. Record the vendor and the guideline name and version in the case record so that any later appeal can reference the exact criteria applied.
2. Pull the applicable criteria. Retrieve the current published guideline for the specific procedure and plan. For Original Medicare, retrieve the governing NCD, LCD, and any Local Coverage Article for the contractor jurisdiction.
3. Assemble against the criteria, element by element. Build the packet in the order the criteria are written, so the reviewer encounters each required element where they expect it.
4. Apply the completeness checklist before submission. Do not submit an incomplete packet to preserve a date. A clinical information request costs more time than the delay it was meant to avoid.
5. Submit electronically. Portal or electronic submission produces a timestamp, a reference number, and a status trail. Fax produces none of those and shifts the burden of proof onto the practice.

1. Record the decision precisely. Capture the authorization number, the exact approved codes, the approved units, the approved laterality, the approved facility, and the valid date range. Approvals are bounded objects; treating them as binary creates the authorized-versus-billed mismatch.
2. Reconcile before the case. Verify the approval against the surgical schedule in the pre-surgical huddle described in Section 4.4.
3. Re-verify after any change. Any change in code, laterality, facility, or date beyond the approved range triggers re-verification.
4. Close the loop after the case. Reconcile the authorized code set against the operative report and the billed code set before the claim is released.

Peer-to-peer review

A peer-to-peer conversation is not a second chance to submit the packet; it is a clinical conversation in which the surgeon has a limited window to address the specific criterion the reviewer found unmet. GoHealthcare's position is that a peer-to-peer request is best understood as a signal of a preventable documentation gap, and that the operational goal is to reduce peer-to-peer volume rather than to perfect peer-to-peer performance.

When a peer-to-peer is unavoidable, prepare it

• Identify the exact guideline, guideline number, and version the reviewer applied, and the specific criterion cited as unmet
• Prepare a one-page brief for the surgeon naming that criterion and the chart evidence responsive to it, with dates
• Confirm the surgeon's availability window before the call is scheduled, since a missed peer-to-peer window frequently converts to a denial
• Document the conversation contemporaneously, including the reviewer's name, credentials, the criterion discussed, and the outcome
• If the outcome is adverse, capture the stated basis verbatim; it becomes the spine of the written appeal

Denial reasons and appeal strategy

Denial reason	Root cause	Prevention	Appeal approach
Conservative therapy not documented or insufficient	Care was delivered but not evidenced with dates, duration, and outcome	Conservative-care ledger maintained prospectively from the first visit	Submit the ledger with dated entries; where therapy occurred outside the practice, obtain the external records rather than attesting to them
Imaging does not support the requested procedure	Report attached but not interpreted; or findings inconsistent with the procedure	Surgeon interprets imaging in the clinical note in criteria-relevant terms	Provide the surgeon's interpretation correlating specific imaging findings to the specific procedure and to the examination
Medical necessity not established	Generic denial masking one specific unmet element	Element-by-element assembly against the published criteria	Demand identification of the specific unmet criterion; recent federal rules require a specific denial reason for impacted payers
Not a covered benefit or site of service not covered	Benefit and site-of-service verification skipped or stale	Financial clearance verifies benefit and place of service before assembly	Distinguish a benefit exclusion from a medical necessity denial; they follow different appeal pathways and different deadlines
Experimental, investigational, or unproven	Procedure, device, or biologic outside the plan's coverage position	Screen new technology against payer policy before it is offered	Cite the specific coverage policy language and any applicable regulatory clearance; recognize that this category is rarely won on clinical argument alone

Denial reason	Root cause	Prevention	Appeal approach
Authorization obtained does not match the claim	Code, laterality, facility, units, or date range drifted between approval and surgery	Pre-surgical huddle reconciliation and post-operative code reconciliation	Frequently correctable administratively rather than through formal appeal; escalate quickly because timely filing runs in parallel
Duplicate or bundled service	Component of a comprehensive service billed separately	Coding review before claim release; quarterly edit currency check	Provide operative documentation of the distinct service, distinct site, or distinct session that supports separate reporting

Operational Action

Categorize every denial at the root-cause level, not the payer level. A monthly report that says 'forty denials from Carrier A' produces no action. A report that says 'twenty-two denials caused by undated conservative therapy, of which eighteen originated from three referring practices' produces a specific intervention. Root-cause categorization is the difference between a denial management function and a denial prevention function.

Payer and Compliance Considerations

Payer-side compliance obligations a practice can invoke

Compliance is not unidirectional. The 2026 regulatory environment created enforceable obligations on payers that orthopedic practices should know how to invoke.

• Decision timeframes. Operational provisions of the CMS Interoperability and Prior Authorization final rule took effect January 1, 2026 for impacted payers, including Medicare Advantage organizations, Medicaid and Children's Health Insurance Program fee-for-service and managed care entities, and qualified health plan issuers on the federally facilitated exchanges. Impacted payers must issue expedited decisions within 72 hours and standard decisions within 7 calendar days.
• Specific denial reasons. Beginning in 2026, impacted payers must provide a specific reason for a denied prior authorization for non-drug services, regardless of whether the request arrived through an application programming interface, a portal, or a fax. A generic 'not medically necessary' response

without an identified unmet criterion should be challenged.

• Public reporting. Impacted payers must publicly report certain prior authorization metrics, which gives practices an external reference point when negotiating or escalating.
• Application programming interfaces. Impacted payers must implement Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization interfaces generally by January 1, 2027, with compliance dates varying by payer type. Practices should be planning their own capability to consume those interfaces rather than waiting.
• State utilization review law. State statutes increasingly impose timelines, clinical peer requirements, criteria transparency obligations, and restrictions on algorithmic denial. These apply to state-regulated products and frequently exceed federal minimums.

Operational Action

Build a payer-obligation reference card for the front line: for each major payer and product line, the applicable decision timeframe, the applicable state law timeline, the escalation contact, and the regulatory complaint pathway. Authorization specialists who can cite a specific obligation resolve stalled cases substantially faster than specialists who can only re-call.

Operational Case Study

Prior authorization barriers

Two structural barriers compounded the documentation gaps. First, the group's authorization staff were assigned by surgeon, which meant that each specialist encountered every delegated vendor occasionally and none of them frequently. No specialist had developed fluency in any single criteria set. Second, the group's payer reference document had not been refreshed in fourteen months. Two commercial products had changed delegated vendors, and one vendor had issued updated musculoskeletal guideline versions. Requests were being assembled against superseded criteria, which produced non-affirmations that looked clinical but were procedural.

Resolution strategy

1. Reorganized the authorization function by payer and delegated vendor rather than by surgeon, creating three vendor-aligned specialist roles with defined criteria ownership.
2. Rebuilt the payer matrix to name, for each payer, product line, and service family, the delegated entity, the governing guideline, and the guideline version, with a quarterly refresh owned by the authorization lead.
3. Redesigned the surgical evaluation template to require symptom duration with a date anchor, a functional instrument score, a structured conservative care ledger, a surgeon imaging interpretation field, an alternatives-considered field, and a medical necessity statement naming procedure, laterality, and intended site of service.
4. Implemented a conservative care ledger populated from the first visit, including a process for requesting external therapy records at intake rather than at the point of authorization.
5. Instituted a weekly pre-surgical huddle reconciling every case scheduled in the following two weeks against the authorization record, with corrections counted and avoided cost estimated.
6. Changed the scheduling rule so that a case is placed on the operative schedule as a held slot at surgical decision but is not confirmed until an active authorization with matching codes, laterality, facility, and date range exists.
7. Ran a contract review on the ambulatory surgery center's commercial agreements against the newly added case types and initiated amendment requests before further cases were scheduled.
8. Built an inpatient justification standard for procedures removed from the Inpatient Only list, requiring an explicit clinical rationale note whenever inpatient status was selected.
9. Rebuilt the denial report around root cause rather than payer, with a monthly intervention assigned to the top three causes.

Lessons learned

• The cancellation metric was measuring the wrong function. Metrics that are reported to the wrong owner generate interventions aimed at the wrong process.
• Nearly every non-affirmation in the sample was a documentation failure rather than a clinical one. The care was appropriate; the record did not say so in the reviewer's language.
• A stale payer matrix produces denials that look clinical and are actually procedural, and those are the hardest denials to diagnose because the clinical argument appears to have failed.
• A Medicare coverage expansion is not an industry-wide change. Commercial contract recognition is a separate question and must be verified before case types are added.
• Removing a procedure from the Inpatient Only list transfers the burden of justifying inpatient status to the medical record.

• Capacity in an authorization team is created by reducing rework far more effectively than by adding staff.
• Template redesign produced durable improvement where prior education efforts had produced temporary improvement.

Frequently Asked Questions

The answers below are operational guidance and are not coverage determinations. Verify payer-specific positions against the current applicable policy.

Does Medicare require prior authorization for orthopedic surgery?

Not generally, and not nationally. Original Medicare has historically adjudicated orthopedic coverage at the claim rather than in advance. The exception is the WISeR Model, which applies prior authorization or pre-payment review to selected service categories for Original Medicare beneficiaries in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. Arthroscopic lavage and arthroscopic debridement for the osteoarthritic knee and cervical fusion are among the included categories. Medicare Advantage plans, by contrast, apply prior authorization extensively.

What is the WISeR Model and does it change coverage rules?

It is a CMS Innovation Center payment model testing technology-assisted prior authorization and pre-payment review in Original Medicare. CMS has stated that it does not change Medicare benefit, coverage, coding, or payment rules and that determinations are made against the relevant National and Local Coverage Determinations and the standard documentation requirements. What it changes is timing: the review happens before the service rather than after the claim.

What happens if a WISeR-included service is performed without a unique tracking number?

For hospital outpatient department and ambulatory surgery center claims, the unique tracking number must appear on the facility claim when prior authorization was obtained. Absent the number, claims for included services are suspended for medical review. Associated services and items, including anesthesia, implanted devices, physician services, and facility fees, follow the determination on the primary service.

Why did the Inpatient Only list phase-out increase our denial risk?

Because the designation functioned as a protective payment rule. While a procedure was on the list, Medicare would not pay for it in an outpatient setting, so the site-of-service argument did not exist. Once removed, inpatient status must be independently justified and is exposed to medical review, and commercial and Medicare Advantage payers can be expected to press for the lower-cost setting.

If a procedure was added to the ASC covered procedures list, can we schedule it?

Only after three separate confirmations. First, that the procedure is on the current calendar year list, verified against the CMS addenda. Second, that the specific payer's contract recognizes the procedure in the ambulatory surgery center place of service, since a commercial payer is not bound by the Medicare list. Third, that the case clears contribution margin after implant and device cost.

Which vendor reviews our orthopedic authorizations?

That depends on the payer, the product line, and often the service family within the same payer. eviCore by Evernorth and Carelon Medical Benefits Management carry the majority of delegated musculoskeletal surgical volume; Cohere Health, Evolent, and TurningPoint appear in specific arrangements. Maintain a payer-product-service-family matrix and refresh it quarterly and at every contract renewal.

Where do we find the criteria a vendor will apply?

Both major vendors publish their guidelines. Carelon posts dated musculoskeletal guidelines with an archive of superseded versions and a preview of upcoming changes. eviCore posts its Comprehensive Musculoskeletal Management guidelines by number and provides a pathway to request the specific criteria applied to an individual determination. Always confirm you are reading the version applicable to that member's plan, because plan-specific versions are maintained in parallel.

How long should conservative therapy last before surgery is authorized?

There is no single answer, and this is exactly the question where practices lose time. The required duration, the acceptable modalities, and the look-back window vary by payer, by vendor guideline, and by joint. The operational answer is to document every modality with start date, end date, frequency, and outcome, so that whatever threshold applies, the evidence exists to demonstrate it.

Our therapy was delivered somewhere else. Is our attestation enough?

Usually not. Reviewers generally expect source documentation rather than a second-hand summary. Build external record acquisition into intake rather than into the authorization step, because requesting records at the point of authorization adds days to a process already under time pressure.

What is the most common reason orthopedic authorizations are non-affirmed?

Insufficient documentation of failed conservative therapy, followed by imaging that is attached but not interpreted by the surgeon in terms that support the specific procedure requested. Both are documentation defects rather than clinical ones.

Can we require the payer to tell us which criterion was unmet?

For impacted payers, operational provisions effective January 1, 2026 require a specific reason for a denied prior authorization for non-drug services regardless of how the request was submitted. Beyond that, state utilization review statutes frequently require criteria transparency. Ask for the guideline name, number, and version and the specific unmet criterion as a standing element of every appeal.

How fast must a payer decide?

For impacted payers under the CMS Interoperability and Prior Authorization final rule, expedited decisions are due within 72 hours and standard decisions within 7 calendar days, effective January 1, 2026. State law may impose shorter timelines for state-regulated products. Know both, and cite the shorter one.

Should we accept a peer-to-peer review?

Yes, when it is offered and the case is defensible, but treat it as a narrow clinical conversation about a specific unmet criterion rather than as a second submission. Prepare a one-page brief for the surgeon identifying the criterion and the responsive chart evidence with dates. Then work on reducing peer-to-peer volume, because a high rate signals preventable documentation gaps.

How often should we refresh our payer and vendor reference?

Quarterly at minimum, and at every contract renewal or delegation change. Vendor guidelines are revised on their own schedules, plan-specific versions exist in parallel, and at least one vendor expressly reserves the right to change guidelines without prior notice.

Authoritative References

Coverage policies, code sets, model parameters, and utilization management criteria change. Verify currency at the time of use.

• CMS Medicare Coverage Database: https://www.cms.gov/medicare-coverage-database
• CMS WISeR Model: https://www.cms.gov/priorities/innovation/innovation-models/wiser
• CMS WISeR Provider and Supplier Operational Guide: https://www.cms.gov/priorities/innovation/files/wiser-provider-supplier-guide.pdf
• CMS Interoperability and Prior Authorization Final Rule: https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-prior-authorization-final-rule-cms-0057-f
• Carelon Current Musculoskeletal Guidelines: https://guidelines.carelonmedicalbenefitsmanagement.com/current-musculoskeletal-guidelines/
• eviCore Clinical Guidelines: https://www.evicore.com/provider/clinical-guidelines

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Developed by GoHealthcare Practice Solutions under the leadership of Pinky Maniri, Founder and Chief Executive Officer. This page is part of the GoHealthcare Orthopedic Surgery Specialty Center and the GoHealthcare MSK Specialty Procedure Library™.

Educational and operational reference only. This content does not replace physician clinical judgment, official payer policy, current CMS guidance, the current official code sets, qualified coding review, contractual review, or legal counsel. Coverage, authorization, coding, and reimbursement requirements must be independently verified before use.