CurrentColorado Rocky Mountain Health PlansPolicy 2026T0105EE

Discogenic Pain Treatment – Commercial and Individual Exchange Medical Policyopen_in_new

UnitedHealthcare Commercial and Individual Exchange medical policy on discogenic pain treatments covering coverage rationale, applicable CPT/HCPCS codes, and clinical evidence summaries for annular closure devices (ACDs), percutaneous injection of allogeneic cellular/tissue-based products, and thermal intradiscal procedures (TIPs). This part (1 of 2) lists not medically necessary procedures, code references, and literature review.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyDiscogenic Pain Treatment – Commercial and Individual Exchange Medical Policyopen_in_new

Policy CodePolicy 2026T0105EE

Change TypeTemplate Update; revised codes list (63032 added)

Effective DateJan 1, 2026

Next Review Date

Key ActionWhen considering percutaneous discectomy for axial or radicular pain, refer to the Medical Policy titled Minimally Invasive Spine Surgery Procedures.

SourceLink

POLICY UPDATE CHANGES

Created shared policy version to support application to Oxford plan membership and updated list of applicable CPT codes to reflect annual edits; added 63032.

Summary of Changes labelled 'Template Update' on 01/01/2026.

3Procedures listed as Not Medically Necessary

9Procedure/HCPCS/CPT codes listed

multipleStudies / meta-analyses cited

1FDA PMA device (Barricaid) referenced

multipleGuidelines summarized

Coverage Summary

UnitedHealthcare Commercial and Individual Exchange medical policy (Policy Number 2026T0105EE, effective 2026-01-01) addressing treatments for discogenic pain. This part (1 of 2) lists procedures determined Not Medically Necessary—specifically Annular closure devices (ACDs), percutaneous injection of allogeneic cellular/tissue-based products, and thermal intradiscal procedures (TIPs)—and provides references to applicable procedure/CPT codes and clinical evidence summaries. The document is intended to support UnitedHealthcare Commercial and Individual Exchange benefit plan interpretation and to identify the procedures and codes discussed in the policy.

This policy (part one of a two-part set) includes the coverage rationale declaring the listed procedures unproven and not medically necessary, cross-references applicable CPT/HCPCS procedure codes, and summarizes the supporting clinical evidence and guidance cited in the full policy.

Key Facts

Effective dateJanuary 1, 2026

Policy number2026T0105EE

Coverage stanceMixed — procedures listed as Not Medically Necessary (ACDs, percutaneous allogeneic injections, TIPs)

SubjectDiscogenic pain treatment (annular closure devices, percutaneous allogeneic injections, thermal intradiscal procedures)

Procedures listed as Not Medically Necessary3

Procedure/HCPCS/CPT codes listed9

FDA PMA device referencedBarricaid

Guidelines summarizedNICE, NASS, ISASS, ASIPP

Not Medically Necessary — Coverage Rationale

Coverage Rationale - Not Medically Necessary

The following procedures are unproven and not medically necessary due to insufficient evidence of efficacy:

Not Medically Necessary Procedures

Annular Closure Devices (ACDs): Annular closure devices (ACDs)
Percutaneous injection of allogeneic cellular/tissue-based products
Thermal intradiscal procedures (TIPs) for treating discogenic pain
Percutaneous discectomy reference note: Note: For percutaneous discectomy for the treatment of axial or radicular pain, refer to the Medical Policy titled Minimally Invasive Spine Surgery Procedures.

Applicable Procedure & Product Codes

Applicable Procedure Codes (reference list)CPT

0627T	Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level.
0628T	Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; each additional level (List separately in addition to code for primary procedure).
0629T	Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level.
0630T	Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; each additional level (List separately in addition to code for primary procedure).
22526	Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level.
22527	Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure).
22899	Unlisted procedure, spine.
63032	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; with repair of annular defect by implantation of bone-anchored annular closure device, including all imaging guidance, 1 interspace, lumbar (List separately in addition to code for primary procedure).
S2348	Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar.

Applicable CPT codes (updated list; 63032 added)CPT

63032

Added to applicable CPT codes list per Policy History

FDA product codes referencedmixed

FTL	surgical mesh, polymeric
FTM	mesh, surgical
GAT	suture, nonabsorbable, synthetic, polyethylene
GEI	electrosurgical cutting and coagulation devices and accessories
GXI	electrosurgical devices
HRX	electrosurgical devices
BSO	electrosurgical devices
BSP	electrosurgical devices

Actions for Providers / Billing

Documentation Required

Reference to alternate policy for percutaneous discectomy

When considering percutaneous discectomy for axial or radicular pain, refer to the Medical Policy titled Minimally Invasive Spine Surgery Procedures.

Documentation Required

Refer to member-specific benefit plan

When deciding coverage, reference the member specific benefit plan document because it may differ from the standard plan; in the event of conflict, the member specific document governs.

Clinical Evidence & Background

Background: Annular closure devices (ACDs) are designed to repair or reinforce the annulus fibrosus after discectomy by bridging or closing the annular defect to reduce reherniation; the Barricaid device is an FDA premarket approved bone-anchored annular closure device with a labeled indication for reducing reherniation and reoperation in select patients with large annular defects following primary lumbar discectomy. Thermal intradiscal procedures (TIPs) involve insertion of a catheter or probe into the disc to apply heat or radiofrequency energy (examples: IDET, IDB/biacuplasty, PIRFT) to alter disc tissue or nociceptors. Percutaneous injections of allogeneic cellular/tissue-based products are donor-derived cell therapies injected into the disc to attempt to stimulate tissue repair.

Overall evidence summary: Across these device types and procedures, the policy finds insufficient or low-quality evidence to support their routine use for treating discogenic low back pain. For ACDs, some trials and meta-analyses report reduced reherniation in selected populations but overall evidence quality is low and safety/complication concerns remain. For percutaneous allogeneic injections, limited RCTs and feasibility studies show mixed results and insufficient high-quality data. For TIPs, systematic reviews and RCTs have provided limited or inconsistent results; guidelines (NICE, NASS, ASIPP/ISASS assessments) and randomized trials do not establish conclusive efficacy and call for additional high-quality randomized studies.

Evidence summary

Definitions

Thermal Intradiscal Procedures (TIPs)Percutaneous procedures inserting a catheter/probe into the disc to apply heat (IDET, IDB, PIRFT) to relieve low back pain.

Revision History

01/01/2026revisedLatest

Created shared policy version to support application to Oxford plan membership; updated list of applicable CPT codes to reflect annual edits and added 63032; updated Clinical Evidence and References sections; archived previous policy versions 2025T0105DD and OUTPATIENT 037.25.

01/01/2026clarified

Template Update: Summary of Changes labelled 'Template Update' noting administrative/template changes with no specific clinical policy statement changes.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyDiscogenic Pain Treatment – Commercial and Individual Exchange Medical Policyopen_in_new

Policy CodePolicy 2026T0105EE

Change TypeTemplate Update; revised codes list (63032 added)

Effective DateJan 1, 2026

Next Review Date

Key ActionWhen considering percutaneous discectomy for axial or radicular pain, refer to the Medical Policy titled Minimally Invasive Spine Surgery Procedures.

SourceLink

On This Page

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Documentation Required

Check federal/state mandates and Medicare coverage guidance

Before applying this policy, check applicable federal or state mandates and Medicare NCD/LCD guidance; in absence of Medicare guidance, a Medicare Advantage Organization (MAO) may create its own coverage determinations using objective evidence-based rationale.

Billing Rule

Use of third-party criteria

UnitedHealthcare may use third-party tools (for example, InterQual) to assist in administering benefits; documentation submitted for review should align with such criteria when those tools are used.

Annular Closure Devices (ACDs)Devices designed to close annular defects after discectomy to reduce reherniation.

Allogeneic cellular/tissue-based productsCell therapies injected into discs derived from donors intended to stimulate tissue repair.

Barricaid Annular Closure DeviceAn FDA premarket approved bone-anchored annular closure device indicated to reduce reherniation and reoperation in skeletally mature patients with a confirmed large annular defect (4-6 mm tall and 6-10 mm wide) following primary discectomy at a single level L4–S1.

PIRFTPercutaneous Intradiscal Radiofrequency Thermocoagulation — a minimally invasive thermal procedure placing an RF probe into the center of the disc (activated 90 seconds at 70°C) to alter disc biomechanics or destroy nociceptive fibers.