CurrentUnitedHealthcarePolicy CS364OH.D

Minimally Invasive Spine Surgery Procedures (for Ohio Only)

Defines UnitedHealthcare medical policy for minimally invasive spine surgery procedures applicable only to Ohio, including coverage rationale, procedures considered unproven/not medically necessary, definitions, literature review summaries, and applicable CPT/HCPCS codes for reference.

Policy Summary

PayerUnitedHealthcare

PolicyMinimally Invasive Spine Surgery Procedures (for Ohio Only)

Policy CodePolicy CS364OH.D

Change TypeDefinitions updated/removed; CPT code additions/removals; supporting information updated

Effective DateApril 1, 2026

Next Review Date

Key ActionProviders must reference InterQual CP criteria for Decompression +/- Fusion, Lumbar and Fusion, Lumbar Spine to determine medical necessity for minimally invasive spine surgery procedures.

SourceLink

POLICY UPDATE CHANGES

Definitions removed: Automated Percutaneous Lumbar Discectomy (APLD); Interlaminar Lumbar Instrumented Fusion (ILIF); Nucleoplasty; Percutaneous or Endoscopic Lumbar Fusion; Transforaminal (TESSYS ® ) and Interlaminar Endoscopic Surgical Systems; Tubular Retractor.

Definitions updated: Axial Lumbar Interbody Fusion (AxiaLIF); Endoscope; Endoscopic Discectomy; Fluoroscopy; Image-Guided Minimally Invasive Lumbar Decompression (MILD ® ); Laparoscopic Anterior Lumbar Interbody Fusion (LALIF); Open Spine Surgery; Percutaneous Image-Guided Lumbar Decompression (PILD); Posterior Lumbar Spine Surgery; Sacroplasty.

Applicable CPT codes 62330 and 62331 were added.

Applicable CPT code 0275T was removed.

Description for CPT code 62287 was revised.

Supporting Information sections (Description of Services, Clinical Evidence, and References) updated; previous policy version CS364OH.C archived.

5Procedures listed as not medically necessary