Back & neck pain care

Applies to:

Commercial group HMO, EPO, POS and PPO plans

Commercial individual MyPriority HMO, POS and PPO plans

Medicaid and Healthy Michigan Plan

Medicare Advantage plans

Medical Policy

• Spine Centers of Excellence - 91531

Back and neck pain clinical practice guideline

• Management of Acute Low Back Pain in Adults

Spine Centers of Excellence (SCOE) evaluations

This evaluation is required before surgical evaluation for Priority Health patients.

Physiatrist-led multi-disciplinary SCOE clinics offer patients the best and most appropriate care. Physiatrists are physicians who are trained to diagnose and manage musculoskeletal problems, including spine- or back-related problems.

SCOEs help ensure that all patients with persistent neck and back pain or other spine-related problems receive a timely, comprehensive, non-surgical medical evaluation.

Through an SCOE, patients receive:

• An evaluation
• In-person acute case reviews
• Treatment that usually does not require surgery

Making a referral to a SCOE

Any participating primary care physician, emergency room physician or urgent care center can refer members to a Priority Health Spine Center of Excellence at any point in the treatment process without prior authorization, including before or after failure of conservative care.

Go to the list of Spine Centers of Excellence

Follow-up after an evaluation

The SCOE physiatrist confirms a diagnosis, and gives patients and the referring physician treatment recommendations. Shared decision-making tools help patients understand the various treatment options, including their risks and benefits.

Become a Spine Center of Excellence practice

Spine Center of Excellence practices helps ensure that all patients with persistent neck and back pain or other spine-related conditions receive a timely, comprehensive, non-surgical medical evaluation before surgery and for an initial surgery referral. To participate in the program review the requirements, complete the application form below and submit them to PH-PELC@priorityhtelath.com.

• Spine Center of Excellence requirements
• Spine Center of Excellence affidavit
• Spine Center of Excellence application form

If you have any questions, contact the Provider Helpline at 800.942.4765.

Spine surgery authorizations

In most cases, unless regular post-operative surgeon visits are necessary, all referrals to orthopedic or neurosurgeons for back pain, neck pain or other new spine-related complaints require: 

• Evaluation by a SCOE (see above). This is applicable prior to surgery and for an initial surgery referral. 
• Prior authorization from provider. Participating providers can use the Authorization Request tool. Non-participating providers should use the authorization forms below.

Forms for requesting spine surgery

• Spine referral for neurosurgeon or orthopedic surgeon evaluation prior authorization form
• Sacroiliac (SI) joint fusion prior authorization form

Post-surgery authorizations

Surgical visits outside the global billing period will follow standard billing and coding practices (see medical policy above for authorization requirements).