ModifiedUnitedHealthcarePolicy CS364KS.02

Minimally Invasive Spine Surgery Procedures (for Kansas Only)

Policy governing coverage and medical necessity criteria for minimally invasive spine surgery procedures applied only to UnitedHealthcare members in Kansas.

Policy Summary

PayerUnitedHealthcare

PolicyMinimally Invasive Spine Surgery Procedures (for Kansas Only)

Policy CodePolicy CS364KS.02

Change TypeDefinitions and coding updates (material coding change)

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and reference current InterQual criteria when requesting coverage for lumbar decompression or fusion.

SourceLink

POLICY UPDATE CHANGES

Updated list of applicable CPT codes: added 62330 and 62331, removed 0275T, and revised description for 62287.

Added definition of 'Transforaminal Lumbar Interbody Fusion'.

Removed definitions of Interlaminar Lumbar Instrumented Fusion (ILIF), Nucleoplasty, Percutaneous or Endoscopic Lumbar Fusion, Transforaminal (TESSYS ® ) and Interlaminar Endoscopic Surgical Systems, and Tubular Retractor.

Updated supporting information sections: Description of Services, Clinical Evidence, and References to reflect current information.

Kansas-onlyState-specific applicability

5+Unproven procedures

InterQualInterQual referenced

19 studies

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~500MILD trial participants

8.2%MILD adverse event rate

Coverage and Evidence-based Stance

InterQual-based coverage

Covered when ALL of the following are met per referenced InterQual criteria

InterQual requirement: Treatment meets the InterQual CP criteria for Decompression +/- Fusion, Lumbar or Fusion, Lumbar Spinesee InterQual

Policy delegates detailed clinical criteria to InterQual; provider must follow InterQual for authorization

Not medically necessary / unproven procedures

Unproven procedures: Axial Lumbar Interbody Fusion (AxiaLIF); Percutaneous Image-Guided Lumbar Decompression (PILD); Percutaneous sacral augmentation (Sacroplasty) with or without balloon or bone cement; Minimally invasive lumbar decompression (MILD); Laparoscopic Anterior Lumbar Interbody Fusion (LALIF)

These procedures are listed as unproven and not medically necessary due to insufficient evidence of efficacy.

Procedure-specific evidence summaries

Coverage stance summaries based on available evidence:

LALIF / R-ALIF summary: LALIF produced similar outcomes to mini-open ALIF but had longer operative times, higher technical demands, and a potentially higher complication rate; LALIF is now rarely used. R-ALIF evidence is limited but suggests potential reductions in certain complications and shorter recovery; however, small study numbers, retrospective designs, heterogeneity, and logistical/cost barriers limit broader adoption.evidence limited/heterogeneous

Further high-quality studies required before standard adoption.

MILD / PILD summary: Systematic reviews and RCTs report statistically and clinically significant short- to mid-term improvements in pain and function for MILD/PILD for stenosis due to hypertrophied ligamentum flavum (meta-analysis: ~500 individuals across 12 trials; adverse event rate ~8.2%). Limitations include heterogeneity across trials, limited long-term data beyond 1–2 years, and gaps in comparisons with open decompression.some RCT evidence up to 2 years

Conservative therapy was typically used prior to intervention in trials.

Percutaneous sacroplasty — evidence summary

Summary of findings from systematic review/meta-analysis

Sacroplasty evidence summary: A systematic review and meta-analysis of 19 studies (n=861) reported technical success 98.9%, clinical success 95.7%, cement leakage 0.3%, and sustained VAS pain reduction through 12 months (baseline VAS 8.32 → 0.923 at 12 months). However, included studies were largely retrospective or prospective case series with no randomized controlled trials; techniques, patient selection, and follow-up were heterogeneous, and other outcomes (mobility, patient satisfaction, narcotic use) were not analyzed.

Results encourage further RCTs comparing sacroplasty with conservative management or sham procedures.

The policy explicitly lists the following procedures as unproven and not medically necessary due to insufficient evidence of efficacy: Axial Lumbar Interbody Fusion (AxiaLIF), Percutaneous Image-Guided Lumbar Decompression (PILD), Percutaneous sacral augmentation (sacroplasty), Minimally Invasive Lumbar Decompression (MILD), and Laparoscopic Anterior Lumbar Interbody Fusion (LALIF).

For sacral insufficiency fractures arising from causes other than osteoporosis or malignancy, the evidence for percutaneous sacroplasty is judged to be insufficient and low quality. The policy notes that current studies do not reliably establish safety or clinical effectiveness for these etiologies and recommends further research, particularly larger randomized controlled trials, to determine the procedure's value in non-osteoporotic/non-malignant SIFs.

A 2019 systematic review and meta-analysis reported high technical (98.9%) and clinical (95.7%) success rates and sustained VAS pain reduction up to 12 months for sacroplasty in osteoporotic or malignant fractures; however, the analysis had important limitations: there were no randomized controlled trials included, most studies were retrospective or prospective case series, and techniques, patient selection, and follow-up were heterogeneous. The meta-analysis also did not assess other clinical outcomes such as mobility, patient satisfaction, or narcotic use, which limits generalizability.

In addition to the five primary procedures listed as unproven (AxiaLIF, PILD, sacroplasty, MILD, LALIF), the policy groups these techniques as spinal procedures for which current evidence does not demonstrate sufficient efficacy to support routine coverage. Because these procedures are designated not medically necessary, claims for them are at risk for denial unless robust new evidence is provided.

Percutaneous laser disc decompression (PLDD) and similar needle-based techniques are associated with higher reoperation/resurgery rates reported in the literature (for example, observational series reporting reoperation rates around 26% and other trials showing substantially higher reoperation frequency versus conventional surgery). The policy cites limited long-term data and low-quality or heterogeneous evidence, and concludes that these concerns—particularly higher subsequent surgery rates and uncertain long-term durability—limit support for routine coverage.

The policy states that FDA marketing clearance or approval information is provided for informational purposes only and that FDA clearance alone is not a basis for coverage decisions. Coverage determinations are made on the basis of the evidence of clinical safety and efficacy as summarized in this policy and applicable benefit plan requirements.

Applicable Procedure and Billing Codes

Applicable procedure and trial codesmixed

0200T	Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed.
0201T	Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed.
22586	Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace.
22630	Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar.
22899	Unlisted procedure, spine.
62287	Decompression, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle-based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar.
62330	Decompression, percutaneous, with partial removal of the ligamentum flavum, including laminotomy for access, epidurography, and imaging guidance (i.e., CT or fluoroscopy), bilateral; one interspace, lumbar.
62331	Decompression, percutaneous, with partial removal of the ligamentum flavum, including laminotomy for access, epidurography, and imaging guidance (i.e., CT or fluoroscopy), bilateral; additional interspace(s), lumbar (List separately in addition to code for primary procedure).
62380	Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar.
G0276	Blinded procedure for lumbar stenosis, percutaneous image-guided lumbar decompression (PILD) or placebo-control, performed in an approved coverage with evidence development (CED) clinical trial.

Device clearances / FDA referenced productsmixed

No codes listed

Applicable CPT code updatesCPT

62330	Added (applicable CPT code listed in policy updates)
62331	Added (applicable CPT code listed in policy updates)
0275T	Removed (code removed from applicable CPT list)
62287	Revised description (per policy updates)

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

InterQual-based Prior Authorization Requirement

Prior authorization required: Coverage for lumbar decompression and fusion procedures is contingent on meeting InterQual® clinical criteria. Providers must obtain prior authorization per UnitedHealthcare policies and reference the InterQual® CP: Procedures — Decompression +/- Fusion, Lumbar and Fusion, Lumbar Spine.

Prior authorization required when InterQual® criteria apply
Link to InterQual® criteria available at UHC provider site

Billing Rule

Prior Authorization and CPT Coding

Providers should obtain prior authorization per UnitedHealthcare procedures. CPT code updates were made effective 03/01/2026; listing of a code in this policy is for reference only and does not guarantee reimbursement or payment.

Definitions and Terminology

APLD definition — Automated Percutaneous Lumbar Discectomy

TermAutomated Percutaneous Lumbar Discectomy (APLD)

DefinitionPercutaneous removal of protruding disc material using a large-bore needle inserted directly into the disc space (NASS, 2025).

Typical approachNeedle-based, percutaneous access to the intervertebral disc space for decompression.

AxiaLIF definition — Axial Lumbar Interbody Fusion

TermAxial Lumbar Interbody Fusion (AxiaLIF)

DefinitionMinimally invasive presacral/trans-sacral technique to access L5–S1 for interbody fusion via a small incision next to the tailbone; abnormal disc is removed, bone graft placed, and large screw(s) may be used for fixation (Cragg et al., 2004).

Clinical Background and Scope

Back pain and radiculopathy from herniated discs are common conditions; many cases improve with nonoperative care and conservative therapies. Surgical decompression is considered for patients with persistent neuropathic symptoms or functional impairment. The policy emphasizes that minimally invasive alternatives (percutaneous, endoscopic, or presacral approaches) have variable evidence quality and that InterQual clinical criteria are referenced for detailed medical necessity determinations prior to considering these procedures.

Policy Summary

PayerUnitedHealthcare

PolicyMinimally Invasive Spine Surgery Procedures (for Kansas Only)

Policy CodePolicy CS364KS.02

Change TypeDefinitions and coding updates (material coding change)

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and reference current InterQual criteria when requesting coverage for lumbar decompression or fusion.

SourceLink

On This Page

Percutaneous laser disc decompression (PLDD) summary: Evidence is limited and mixed; some randomized and observational studies report higher reoperation/resurgery rates compared with conventional surgery, creating uncertainty about long-term benefit and appropriate indications.higher reoperation risk

Not established as a routine replacement for open discectomy.

Endoscopic discectomy summary: Systematic reviews of randomized trials indicate endoscopic discectomy yields similar or slightly better patient satisfaction, reduced blood loss, and shorter hospital stays versus open discectomy, but additional high-quality independent trials and cost-effectiveness data are needed.moderate evidence

Further independent RCTs recommended.

Percutaneous sacroplasty summary: For osteoporotic or malignant sacral fractures, meta-analyses report high technical (98.9%) and clinical (95.7%) success with significant short-term pain reduction; for sacral insufficiency fractures from causes other than osteoporosis or malignancy, evidence is insufficient and low quality. Comparative RCTs are lacking.evidence varies by fracture etiology

Further randomized studies recommended.

Updated CPT codes: 62330 and 62331 added; 0275T removed; 62287 description revised
Inclusion of a code does not imply coverage or right to reimbursement — verify member benefits and plan rules

Denial Risk

Denial Risk for Unproven Procedures

Procedures designated as unproven in this policy (for example, AxiaLIF, PILD, sacroplasty, MILD®, LALIF, and certain robotic or laparoscopic variants) are considered not medically necessary due to insufficient evidence and may be denied. Submit documentation if seeking consideration, but anticipate denial risk.

Unproven / not medically necessary: Axial Lumbar Interbody Fusion (AxiaLIF®), Percutaneous Image-Guided Lumbar Decompression (PILD), Percutaneous sacral augmentation (sacroplasty), MILD®, LALIF
Failure to document plan-specific exceptions or applicable contractual requirements may lead to claim denial

Denial Risk

PILD Evidence Insufficiency

The evidence for percutaneous image-guided lumbar decompression (PILD) is insufficient to determine net health benefit. Prior authorization or coverage denial may apply; provide robust documentation if requesting coverage.

Hayes Health Technology Assessment (2025) found low-quality evidence and uncertainty about long-term durability and comparative effectiveness
PILD (including image‑guided MILD® technique) typically requires prior authorization and thorough documentation of prior treatments and indications

Documentation Required

Conflicting Benefit Rules May Cause Denial

Benefit plan terms (federal, state, or contractual) govern coverage decisions and may conflict with this policy. In the event of conflict, those plan-specific requirements supersede the policy and failure to follow them or to document required plan-specific criteria can result in denial.

Always verify federal/state/contractual benefit plan requirements before submitting requests
If plan rules differ from this policy, follow the governing plan and document compliance

Billing Rule

Coding and Documentation Note

Inclusion of procedure or diagnosis codes in this policy is for reference only and does not guarantee reimbursement. Follow plan-specific billing rules, submit appropriate modifiers, and ensure coding supports the medical necessity documented in the prior authorization and claims.

Code lists are not exhaustive and may change annually
Verify member benefits, submit required documentation, and use correct CPT/ICD-10 codes and modifiers

Documentation Required

Outcome Measures and Prior Conservative Therapy

Document objective outcome measures and the required trial of conservative therapy prior to surgical or minimally invasive interventions. Use validated scales (e.g., ODI, VAS/NPRS, Zurich Claudication Questionnaire) and record duration and modalities of conservative treatment attempts.

Record baseline and follow-up scores for ODI, VAS/NPRS, and Zurich Claudication Questionnaire where applicable
Document specific conservative therapies tried (physical therapy, medications, epidural injections, activity modification), duration, and response

Prior Authorization

Conservative Therapy Prior to Surgery

Conservative therapy is emphasized as a prerequisite for many minimally invasive decompression procedures. Trials of MILD® and related procedures included prior conservative treatment; document attempts, duration, and lack of adequate response before requesting authorization for surgery.

Document that conservative care was attempted and failed (type and length of therapy) — absence of documented conservative therapy may lead to denial
Fusion is not indicated for isolated lumbar stenosis without instability or deformity per AANS/CNS guidance

Documentation Required

Documentation of Plan-Specific Criteria

When requesting prior authorization or adjudicating claims, include plan-specific criteria and any federal/state/contractual requirements. Thorough documentation demonstrating compliance with InterQual® criteria, conservative therapy prerequisites, and measured outcomes will support medical necessity determinations.

Attach InterQual® criteria results or decision support to the request when applicable
Include clinical notes, outcome measures, and documentation of plan-specific requirements

Alternate namesTrans-sacral, transaxial, paracoccygeal interbody fusion.

Endoscopic discectomy / Endoscope definition — endoscope-based discectomy

TermEndoscopic Discectomy / Endoscope

DefinitionUse of an Endoscope—an illuminated diagnostic instrument for direct visualization—to remove herniated disc material via minimally invasive surgical approach (NASS, 2025).

Clinical contextEndoscopic discectomy provides visualization and targeted removal of disc fragments with less tissue disruption than open surgery.

MILD definition — Image-Guided Minimally Invasive Lumbar Decompression definition

TermMILD (Image-Guided Minimally Invasive Lumbar Decompression)

DefinitionAn image-guided, minimally invasive procedure to decompress the lumbar spine for central canal stenosis caused by thickened ligamentum flavum (Zhang et al., 2025).

Evidence noteSystematic reviews/clinical trials report significant short- to mid-term pain and function improvement with low adverse event rates (~8.2%), but heterogeneity and limited long-term data remain.

PILD definition — Percutaneous Image-Guided Lumbar Decompression definition

TermPILD (Percutaneous Image-Guided Lumbar Decompression)

DefinitionPercutaneous, image-guided removal of thickened tissue (often hypertrophied ligamentum flavum) to enlarge the spinal canal and relieve posterior lumbar spinal stenosis; performed under fluoroscopic or other imaging guidance.

Evidence noteHayes and policy reviews identify low-quality evidence with improvements lasting up to 1–2 years but uncertainty about long-term durability and comparative effectiveness.

Sacroplasty definition — image-guided cement augmentation of sacral insufficiency fractures

TermSacroplasty (percutaneous sacral augmentation)

DefinitionImage-guided injection of polymethyl methacrylate (PMMA) cement into sacral insufficiency fracture sites via multiple possible approaches to provide mechanical stabilization and pain relief.

Evidence distinctionMeta-analysis shows high technical (98.9%) and clinical (95.7%) success for osteoporotic or malignant sacral fractures, but evidence is insufficient/low-quality for non-osteoporotic/non-malignant etiologies.

LALIF definition — Laparoscopic Anterior Lumbar Interbody Fusion definition

TermLaparoscopic Anterior Lumbar Interbody Fusion (LALIF)

DefinitionMinimally invasive anterior approach using small abdominal incisions and endoscopic access to perform anterior lumbar interbody fusion in the lumbar region.

Comparative noteSystematic review indicates LALIF has similar outcomes to mini-open ALIF but longer operative times, higher technical demands, and potentially higher complication rates; LALIF is now rarely used.

LALIF / R-ALIF definition — laparoscopic and robotic-assisted anterior lumbar interbody fusion

TermLALIF / R-ALIF (laparoscopic and robotic-assisted anterior lumbar interbody fusion)

DefinitionMinimally invasive anterior lumbar fusion variants including laparoscopic ALIF and robotic-assisted ALIF; R-ALIF uses robotic systems to assist anterior approach and instrumentation.

Evidence noteLimited evidence for R-ALIF suggests potential reduced complications and shorter recovery, but small study numbers, heterogeneity, training/logistical barriers, and cost limit broad adoption.

MILD / PILD combined definition — minimally invasive percutaneous image-guided decompression terminology

TermMILD / PILD combined terminology

DefinitionRefers to minimally invasive lumbar decompression performed percutaneously under image guidance (often targeting hypertrophied ligamentum flavum); MILD is the proprietary/brand-named technique commonly reported in the literature and overlaps with PILD descriptions.

Clinical expectationClinical trials of these techniques generally required prior conservative therapy and reported short- to mid-term symptom improvement, with uncertainties about long-term durability.

Percutaneous sacroplasty definition — evidence distinctions based on fracture etiology

TermPercutaneous sacroplasty — evidence distinctions

DefinitionWhile sacroplasty denotes image-guided PMMA cement augmentation for sacral insufficiency fractures, evidence and guideline support differ by etiology: osteoporotic or malignant fractures have supportive meta-analytic data, but fractures from other causes have insufficient and low-quality evidence.

Research needPolicy recommends larger RCTs to establish safety and long-term effectiveness for non-osteoporotic/non-malignant sacral insufficiency fractures.

Transforaminal Lumbar Interbody Fusion — newly added definition in policy

TermTransforaminal Lumbar Interbody Fusion (new definition)

DefinitionAdded to policy definitions as a recognized interbody fusion approach (policy update effective 03/01/2026).

Policy noteIn policy history, definition of Transforaminal Lumbar Interbody Fusion was added and multiple prior definitions were removed or updated concurrently.

Policy definitions updates — removed/updated prior definitions such as ILIF, Nucleoplasty, Percutaneous/Endoscopic Lumbar Fusion, TESSYS, Tubular Retractor

SummaryPolicy definitions updated (03/01/2026): added Transforaminal Lumbar Interbody Fusion; removed prior definitions including Interlaminar Lumbar Instrumented Fusion (ILIF), Nucleoplasty, Percutaneous or Endoscopic Lumbar Fusion, TESSYS and Interlaminar Endoscopic Surgical Systems, and Tubular Retractor.

Operational noteSeveral existing definitions were revised (APLD, AxiaLIF, Endoscope, Endoscopic Discectomy, Fluoroscopy, MILD, Interbody Fusion, LALIF, PELD, PILD, Posterior Lumbar Spine Surgery, Sacroplasty) to reflect current information.

Effective date03/01/2026 (policy history entry).