CurrentUnitedHealthcarePolicy CSNCT0365.04

Spinal Fusion and Decompression (for North Carolina Only)

State-specific UnitedHealthcare medical policy applying only to North Carolina; references North Carolina Medicaid Clinical Coverage Policy 1A-30 for medical necessity criteria for spinal surgeries and provides an extensive list of applicable procedure and diagnosis codes for spinal fusion and decompression. Includes coding notes, FDA device information, related policies, and revision history.

Policy Summary

PayerUnitedHealthcare

PolicySpinal Fusion and Decompression (for North Carolina Only)

Policy CodePolicy CSNCT0365.04

Change TypeCoding notation added; related policy link updated

Effective DateFeb 1, 2025

Next Review Date

Key ActionFor medical necessity clinical coverage criteria, providers must refer to North Carolina Medicaid Clinical Coverage Policy Physician: 1A-30 (Spinal Surgeries) when submitting claims or prior authorization requests; UnitedHealthcare policy delegates clinical criteria to that state policy.

POLICY UPDATE CHANGES

Added notation that CPT codes 0179T, 0202T, 0219T, 0220T, 0221T, 0222T, 63052, and 63053 are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.

Related Policies updated reference link to reflect the current policy title for Spinal Fusion and Bone Healing Enhancement Products (for North Carolina Only).

~150Listed CPT Codes (approx.)

8Codes Not on NC Medicaid Fee Schedule

1State-Specific Policy (NC only)

Coverage Summary & Rationale

This is a state-specific UnitedHealthcare medical policy that applies only to North Carolina. UnitedHealthcare delegates medical necessity clinical coverage criteria for spinal surgeries to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy Physician: 1A-30 and provides an extensive reference list of procedure and diagnosis codes related to spinal fusion and decompression, including coding notes and revision history.

Policy Metadata

effective dateFebruary 1, 2025

last reviewFebruary 1, 2025

policy_numberCSNCT0365.04

subjectSpinal Fusion and Decompression (North Carolina Only)

statusCURRENT

State-specificNorth Carolina (policy applies only to the state of North Carolina)

Coverage Rationale

For medical necessity clinical coverage criteria, refer to the North Carolina Medicaid ...

State Applicability: This policy applies only to the state of North Carolina.
Delegation to NC Medicaid Clinical Criteria: Medical necessity clinical coverage criteria are determined by North Carolina Medicaid Clinical Coverage Policy Physician: 1A-30; UnitedHealthcare defers to that policy for clinical criteria.

Provider Requirements & Billing Notes

Documentation Required

Defer to NC Medicaid Clinical Coverage Policy for Medical Necessity

Providers must defer to the North Carolina Medicaid Clinical Coverage Policy: Physician: 1A-30 (Spinal Surgeries) for medical necessity clinical coverage criteria when submitting claims or prior authorization requests. UnitedHealthcare delegates determination of clinical medical necessity to that North Carolina Medicaid policy; this policy applies only to the state of North Carolina.

Billing Rule

Codes Provided for Reference Only

The procedure and diagnosis codes listed in this policy are provided for reference only and their inclusion does not guarantee coverage or reimbursement. Verify applicability with the State of North Carolina Medicaid Fee Schedule and confirm federal, state, or contractual requirements and any payer-specific rules prior to billing; codes marked with an asterisk are not on the NC Medicaid Fee Schedule and therefore may not be covered by NC Medicaid.

Applicable Procedure & Fee-Schedule Notes

Reference Procedure and Diagnosis Codes (spinal fusion/decompression, may not be all-inclusive)CPT

0179T	Electrocardiogram, 64 leads or greater; with graphic presentation and analysis; tracing and graphics only, without interpretation and report.
0202T	Posterior vertebral joint(s) arthroplasty [e.g: facet joint(s) replacement]; including facetectomy; laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement; when performed including fluoroscopy, single level, lumbar spine.
0219T	Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical.
0220T	Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic.
0221T	Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar.
0222T	Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; each additional vertebral segment (List separately in addition to code for primary procedure).
22206	Osteotomy of spine, posterior or posterolateral approach, 3 columns, vertebral segment; thoracic.
22207	Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment; lumbar.
22208	Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure).
22210	Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical.

1–10 of 135

1/14

Codes Not on NC Medicaid Fee Schedule (may not be covered by NC Medicaid)CPT

0179T	Not on NC Medicaid Fee Schedule (per policy notation).
0202T	Not on NC Medicaid Fee Schedule.
0219T	Not on NC Medicaid Fee Schedule.
0220T	Not on NC Medicaid Fee Schedule.
0221T	Not on NC Medicaid Fee Schedule.
0222T	Not on NC Medicaid Fee Schedule.
63052	Not on NC Medicaid Fee Schedule.
63053	Not on NC Medicaid Fee Schedule.

Background & Definitions

This UnitedHealthcare policy for North Carolina references the North Carolina Medicaid Clinical Coverage Policy Physician: 1A-30 for medical necessity clinical coverage criteria and defers to that state policy when determining coverage for spinal surgeries. The policy includes an Applicable Codes section listing numerous CPT procedure codes related to spinal fusion and decompression and notes which codes are not on the State of North Carolina Medicaid Fee Schedule. The U.S. Food and Drug Administration (FDA) information in this policy is provided for informational purposes only (not a basis for coverage) and includes device references such as approved dynamic stabilization systems (for example, the TOPS System) and statements about the FDA approval status of facet arthroplasty devices.

Policy Applicability: This medical policy applies only to the state of North Carolina; in the event of a conflict, federal, state, or contractual requirements for benefit plan coverage govern.

Deference to State Clinical Criteria: UnitedHealthcare defers to the North Carolina Medicaid Clinical Coverage Policy Physician: 1A-30 for medical necessity clinical coverage criteria for spinal surgeries.

Document Changes & Timeline

2025-02-01material

Applicable Codes section updated 02/01/2025; supporting information archived previous policy version CSNCT0365.03.

2025-02-01material

2025-10-01non-materialLatest