CurrentUnitedHealthcarePolicy CSNCT0365.05

Spinal Fusion and Decompression (for North Carolina Only)

UnitedHealthcare medical policy applicable only to North Carolina that references North Carolina Medicaid Clinical Coverage Policy 1A-30 for medical necessity criteria for spinal fusion and decompression procedures; provides applicable CPT/HCPCS codes for reference, documentation guidance, FDA/device information, related policies, and revision history.

Policy Summary

PayerUnitedHealthcare

PolicySpinal Fusion and Decompression (for North Carolina Only)

Policy CodePolicy CSNCT0365.05

Change TypeAdministrative updates and code list revisions

Effective DateJune 1, 2026

Next Review Date

Key ActionProviders must maintain legible medical records that fully support medical necessity for requested spinal fusion/decompression services and make them available upon request.

POLICY UPDATE CHANGES

Added reference link to the Medical Policy titled Interspinous Fusion and Decompression Devices (for North Carolina Only).

Added/expanded language under Medical Records Documentation Used for Reviews to specify that benefit coverage is determined by federal, state, or contractual requirements and to detail documentation expectations.

Removed CPT codes 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, and 63265 from the applicable codes list.

Revised description for CPT code 22614.

Updated FDA section to reflect the most current information (including facet joint replacement TOPS System PMA note).

~120Procedure codes listed

1Referenced external clinical policy (NC Medicaid 1A-30)

1State-specific applicability (North Carolina only)

Coverage Summary

This UnitedHealthcare Medical Policy titled Spinal Fusion and Decompression (for North Carolina Only) applies only to the state of North Carolina and references North Carolina Medicaid Clinical Coverage Policy Physician: 1A-30 for medical necessity determinations. The policy effective date and most recent review are June 1, 2026 (Effective / Last review: 2026-06-01).

Policy metadata

policy_numberCSNCT0365.05

effective_dateJune 1, 2026

last_reviewJune 1, 2026

coverage_stanceMixed - defers to NC Medicaid Clinical Coverage Policy 1A-30 for medical necessity

state_applicabilityNorth Carolina only

Medical‑Necessity Criteria

Coverage Rationale / Medical Necessity

For medical necessity clinical coverage criteria, refer to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Physician: 1A-30, Spinal Surgeries.

ALL of the following

This Medical Policy only applies to the state of North Carolina.
Medical necessity clinical coverage criteria are determined by North Carolina Medicaid Clinical Coverage Policy Physician: 1A-30 (Spinal Surgeries).
Medical records documentation must fully support medical necessity and may be required for review (including relevant medical history, physical examination, and diagnostic test results).
Inclusion of procedure/diagnosis codes in this policy is for reference only and does not by itself imply coverage or reimbursement.

Not Covered / State Limitations

Inclusion of procedure or diagnosis codes in this policy is provided for reference only and does not by itself imply coverage, reimbursement, or guarantee claim payment; benefit coverage is determined by federal, state, or contractual requirements and applicable laws.

Per the policy's State Fee Schedule Note, codes labeled with an asterisk (*) 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.

Coding (CPT/HCPCS)

Applicable Procedure Codes (CPT/HCPCS) - Reference list (may not be all inclusive)mixed

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, 1 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 primary procedure).
22210	Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical.

1–10 of 126

1/13

State Fee Schedule Notemixed

*	Codes labeled with an asterisk (*) 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.

Provider Actions

Documentation Required

Medical records must support medical necessity

Providers must maintain legible medical records that fully support medical necessity for requested spinal fusion/decompression services and make them available upon request. Documentation should include relevant history, physical examination, and results of pertinent diagnostic tests or procedures; documentation may be required for review but does not guarantee coverage.

Relevant medical history
Physical examination
Results of pertinent diagnostic tests or procedures

Prior Authorization

Refer to NC Medicaid clinical coverage for medical necessity determinations

Prior authorization and coverage determinations for spinal fusion and decompression should follow North Carolina Medicaid Clinical Coverage Policy, Physician: 1A-30. UnitedHealthcare defers to NC Medicaid 1A-30 for medical necessity criteria and prior authorization/coverage decisions.

Background

This UnitedHealthcare policy applies only to North Carolina and explicitly defers to the North Carolina Medicaid Clinical Coverage Policy Physician: 1A-30 (Spinal Surgeries) for substantive medical necessity criteria for spinal fusion and decompression procedures.

The policy provides administrative guidance on documentation requirements (medical records must fully support medical necessity and may be required for review) and includes FDA/device informational references for spinal fusion and decompression devices.

The policy also contains a long CPT/HCPCS reference list of applicable procedure codes for spinal fusion and decompression (provided for reference and may not be all inclusive).

Medical records documentation: Includes relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures that fully support medical necessity; documentation should be legible, maintained in the patient's medical record, and made available upon request.

State Fee Schedule Note: Codes labeled with an asterisk (*) 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.

Revision History

06/01/2026addedLatest

Added reference link to the Medical Policy titled Interspinous Fusion and Decompression Devices (for North Carolina Only).

06/01/2026revised

Added/expanded language under Medical Records Documentation Used for Reviews to specify that benefit coverage is determined by federal, state, or contractual requirements; that medical records documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage; and that the patient's medical record must contain documentation (including relevant medical history, physical examination, and results of pertinent diagnostic tests) that fully supports medical necessity and be made available upon request.