ModifiedUnitedHealthcarePolicy CS364PA.D

Minimally Invasive Spine Surgery Procedures (for Pennsylvania Only)

Policy governing coverage and medical necessity determinations for specified minimally invasive spinal procedures for members in Pennsylvania. Affects providers requesting authorization for these procedures under UnitedHealthcare in Pennsylvania.

Policy Summary

PayerUnitedHealthcare

PolicyMinimally Invasive Spine Surgery Procedures (for Pennsylvania Only)

Policy CodePolicy CS364PA.D

Change TypeDefinitions and CPT code updates

Effective Date03/01/2026

Next Review DateN/A

Key ActionUse the updated CPT codes and follow Pennsylvania-specific prior authorization pathways when submitting requests.

SourceLink

POLICY UPDATE CHANGES

Added definition of 'Transforaminal Lumbar Interbody Fusion'.

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

Added CPT codes 62330 and 62331 to applicable CPT code list.

Removed CPT code 0275T.

Revised description for CPT 62287.

Updated clinical evidence summaries and references to incorporate recent systematic reviews and meta-analyses comparing Endo-LIF/Endo-TLIF/PE-TLIF/BE-LIF with MIS-TLIF and PLIF.

9procedures listed as unproven/not medically necessary

PA onlypolicy application

Added 2CPT edits (62330, 62331)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Multipledefinitions revised/added/removed

Coverage Criteria and Evidence Summary

Coverage Rationale and Unproven / Not Medically Necessary Procedures

The following spinal procedures are considered unproven and not medically necessary due to insufficient evidence of efficacy and/or inadequate quality of comparative data:

ALL of the following

Axial Lumbar Interbody Fusion (AxiaLIF) — percutaneous presacral access to L5–S1
Percutaneous Image-Guided Lumbar Decompression (PILD) — including the MILD® procedure and other image-guided posterior decompression techniques
Percutaneous sacral augmentation (sacroplasty), with or without balloon or bone cement, for causes other than osteoporotic or malignant sacral insufficiency fractures
Automated Percutaneous Lumbar Discectomy (APLD)
Percutaneous Endoscopic Lumbar Discectomy (PELD) and other endoscopic lumbar discectomy approaches when proposed as replacements for standard open discectomy
Minimally Invasive Lumbar Decompression (MILD®) when evidence is insufficient to demonstrate long-term net health benefit or comparison with open decompression
Laparoscopic Anterior Lumbar Interbody Fusion (LALIF) and robotic-assisted anterior approaches (R-ALIF) where evidence is limited and technique is rarely used
Transforaminal Lumbar Interbody Fusion (TLIF) performed using only endoscopic visualization (endoscopic TLIF/Endo-TLIF/PE-TLIF/biportal or uniportal endoscopic TLIF techniques)

Axial Lumbar Interbody Fusion Evidence Summary

Axial Lumbar Interbody Fusion (AxiaLIF): Evidence summary and coverage-relevant findings

ALL of the following

No randomized controlled trials were identified comparing AxiaLIF with standard interbody fusion techniques; evidence is primarily retrospective case series and single-center comparative retrospective studies.
Available observational studies report mixed results: some series report improvements in pain and function, but comparative and longer-term data show higher rates of pseudarthrosis, complications, and revision surgery in AxiaLIF cohorts compared with ALIF in limited retrospective comparisons.
ECRI and guideline reviews have concluded the available evidence is at high risk of bias and insufficient to establish comparative effectiveness; NICE recommends use only with special arrangements for governance or research.
Conclusion: Evidence is insufficient to demonstrate that AxiaLIF provides a net health benefit compared with standard surgical approaches; therefore it is considered unproven / not medically necessary for routine use.

Percutaneous Image-Guided Lumbar Decompression (PILD/MILD®)

Percutaneous Image-Guided Lumbar Decompression (PILD / MILD®): evidence synthesis and considerations

ALL of the following

Some RCTs and higher-level studies exist comparing PILD/MILD® with conservative therapies or ESI, and professional consensus statements have rated evidence as supportive for selected patients with ligamentum flavum hypertrophy.
Systematic reviews and health technology assessments (Hayes, ECRI) note improvements in pain and function up to 1–2 years in selected populations but identify limitations including risk of bias, heterogeneity, and uncertainty about long-term durability.
Comparative data versus open decompression are limited; RCTs comparing PILD to open decompression are lacking, and trials have been at risk of performance and expectation bias.
Conclusion: While some evidence supports short-term benefit in carefully selected individuals, overall evidence quality and long-term comparative effectiveness remain uncertain; policy positions reflect these limitations.

Percutaneous Sacroplasty Evidence Summary

Percutaneous Sacroplasty: coverage-relevant evidence summary

ALL of the following

For osteoporotic or malignant sacral fractures, systematic reviews of case series report high technical and clinical success rates with low immediate complication rates, but studies are nonrandomized and at risk of bias.
For sacral insufficiency fractures due to other causes, Hayes concluded the overall body of evidence is poor and provides minimal support for routine use; guidelines and position statements offer no or unclear support.
Conclusion: Evidence is insufficient to support sacroplasty for SIFs from non-osteoporotic/non-malignant causes; for osteoporotic or malignant fractures, the evidence remains limited to low-quality studies and long-term outcomes and comparative effectiveness versus conservative care are uncertain.

Percutaneous/Endoscopic Discectomy and APLD Evidence Summary

Percutaneous and Endoscopic Lumbar Discectomy (PLDD, PELD) and APLD: evidence highlights

ALL of the following

Meta-analyses and RCT data comparing endoscopic discectomy with open microdiscectomy show similar short- and mid-term outcomes, less blood loss, shorter hospital stay, and mixed findings on satisfaction; however, many trials are small and at risk of bias.
Some analyses report higher recurrence or reoperation rates with PELD/PLDD in certain series, raising concerns if used as a wholesale replacement for open discectomy.
Nucleoplasty and automated percutaneous techniques (APLD) lack high-quality RCT evidence demonstrating long-term net health benefit compared with standard surgical discectomy.
Conclusion: Endoscopic approaches may offer short-term perioperative advantages but evidence for long-term equivalence or superiority is limited and mixed; certain percutaneous decompression techniques show higher reoperation rates in some studies.

Endoscopic / Minimally Invasive TLIF Evidence Summary

Transforaminal Lumbar Interbody Fusion (TLIF) using endoscopic or purely percutaneous endoscopic visualization: coverage and evidence considerations

ALL of the following

Comparative systematic reviews and meta-analyses of Endo-LIF/PE-TLIF versus MIS-TLIF show similar short- to mid-term clinical and fusion outcomes in pooled, mostly nonrandomized studies, with endoscopic approaches offering less blood loss and shorter hospital stay but often longer operative times.
Most available studies are nonrandomized, single-center, and have relatively short follow-up; risk of bias and heterogeneity limit confidence in long-term comparative safety and effectiveness.
ECRI reviews note low-quality evidence at high risk of bias, preventing definitive conclusions about how percutaneous transforaminal endoscopic approaches compare with other MIS or open techniques.
Conclusion: Endoscopic-only TLIF techniques are considered investigational / not medically necessary for routine use given the current evidence limitations regarding long-term outcomes, complication profiles, and generalizability.

Coverage Criteria (Operational Summary)

Coverage criteria (operational summary)

ALL of the following

The procedures listed in this section are considered unproven and not medically necessary for routine clinical use due to insufficient high-quality evidence demonstrating improved net health outcomes compared with established surgical approaches.
For indications where some limited evidence exists (for example, PILD/MILD® in select patients with ligamentum flavum hypertrophy), coverage decisions should require documentation of patient selection, prior conservative therapy, and informed consent acknowledging the uncertainties and potential alternatives.
Procedures should be considered investigational/not medically necessary when proposed as replacements for standard, guideline-supported care (e.g., using endoscopic fusion techniques instead of established fusion methods) in the absence of robust comparative evidence.

Applicable Codes and Coding Updates

Applicable CPT/CPT-like procedure codesCPT

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.

HCPCS / otherHCPCS

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.

No explicit codes listed in this document segmentmixed

No codes listed

Applicable CPT codes updatedCPT

62330	Added CPT code (per policy updates)
62331	Added CPT code (per policy updates)
0275T	Removed CPT code (per policy updates)
62287	Description revised (per policy updates)

Applicable CPT code editsCPT

62330	Added to applicable CPT codes
62331	Added to applicable CPT codes
0275T	Removed from applicable CPT codes
62287	Description revised

Coding thresholds / None specified

NoteNone specified in this section.

ContextThis policy excerpt indicates no additional coding thresholds or numeric limits are specified in the provided sections.

Action for providersRefer to the full policy coding section and member benefit plan for applicable prior authorization and coding requirements.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Pennsylvania Prior Authorization Requirement

This Medical Policy only applies to the state of Pennsylvania. Any requests for services that do not meet criteria set in the Pennsylvania Exceptions (PARP) will be evaluated on a case-by-case basis and may be denied.

PA-specific authorization pathways and PARP exceptions apply.

Prior Authorization

Prior Authorization Advisable for Low-Evidence Procedures

Prior authorization is advisable for minimally invasive or percutaneous spinal procedures with inconsistent or low-quality evidence. Providers should verify member benefits and obtain authorization when indicated to avoid retrospective denials.

Check member benefits and InterQual criteria that may be used.
Use updated CPT codes (e.g., 62330, 62331) and note removal of 0275T on prior authorizations.

Background and Policy Scope

Low back pain and radiculopathy from disc herniation are common conditions that frequently improve with nonoperative care; surgery is generally reserved for patients with persistent or progressive neurologic symptoms or disabling pain after an adequate trial of conservative management. Minimally invasive techniques have been developed as alternatives to open procedures, but the policy emphasizes that evidence quality varies by technique and that many less‑established procedures lack high‑quality randomized data demonstrating durable net health benefit.

Definitions

Automated Percutaneous Lumbar Discectomy (APLD)

DefinitionAutomated Percutaneous Lumbar Discectomy (APLD): The percutaneous removal of protruding disc material using a large-bore needle inserted directly into the disc space (NASS, 2025).

ApproachPercutaneous (through the skin) needle-based disc nucleus removal.

Indication contextDescribed as a minimally invasive technique for symptomatic disc herniation; updated definition reflected in the 03/01/2026 policy revision.

Axial Lumbar Interbody Fusion (AxiaLIF)

DefinitionAxial Lumbar Interbody Fusion (AxiaLIF): A minimally invasive presacral/transaxial technique to access L5–S1 (and sometimes L4–S1) via a small incision near the tailbone for interbody fusion, placing bone graft in the disc space and supplemental instrumentation as indicated.

Surgical access

Policy Update Summary

2026-03-01Definitions added/removed/updatedLatest

Added definition of 'Transforaminal Lumbar Interbody Fusion'; removed definitions for Interlaminar Lumbar Instrumented Fusion (ILIF), Nucleoplasty, Percutaneous or Endoscopic Lumbar Fusion, TESSYS® and interlaminar endoscopic systems, and Tubular Retractor; updated multiple other procedure and device definitions.

2026-03-01CPT code edits

Updated applicable CPT codes to reflect annual edits: added CPT codes 62330 and 62331, removed CPT code 0275T, and revised the description for CPT 62287.

2026-03-01

Policy Summary

PayerUnitedHealthcare

PolicyMinimally Invasive Spine Surgery Procedures (for Pennsylvania Only)

Policy CodePolicy CS364PA.D

Change TypeDefinitions and CPT code updates

Effective Date03/01/2026

Next Review DateN/A

Key ActionUse the updated CPT codes and follow Pennsylvania-specific prior authorization pathways when submitting requests.

SourceLink

On This Page

Prior Authorization

Prior Authorization Recommended for Percutaneous/Endoscopic Lumbar Procedures

Due to inconsistent evidence and noted risk of subsequent surgeries or recurrence, obtain prior authorization for percutaneous and endoscopic lumbar procedures and document prior conservative management.

Document symptom duration and prior conservative therapies (e.g., physical therapy, medications, injections) and their duration.
Providers should expect utilization review and InterQual criteria to be applied where available.

Documentation Required

Device-Specific Operative Documentation Required

When requesting authorization or submitting operative reports for novel minimally invasive surgical devices or techniques (including novel MIS bone graft delivery devices), include detailed operative notes and device information to support medical necessity.

Include device name, model, manufacturer, and FDA status (if available).
Describe intraoperative findings, approach, and rationale for device use.

Documentation Required

Required Clinical History and Prior Management

Document a clear clinical history that includes symptom duration, neurologic findings, imaging results, and prior management. Explicitly state failure of conservative therapy before considering surgical decompression or percutaneous/endoscopic interventions.

Record duration of symptoms (minimums used in studies, e.g., ≥3 months where applicable).
Detail prior conservative therapies and response (physical therapy, medications, injections).
Include imaging findings that correlate with clinical symptoms.

Step Therapy

Conservative Therapy Prerequisite

Conservative therapy is generally required prior to surgical decompression and was a prerequisite in studies of MILD and other minimally invasive procedures; document prior conservative treatments and rationale for proceeding to a procedural intervention.

Document specific conservative modalities attempted and duration.
If a deviation from typical conservative management is requested, provide justification for exception.

Step Therapy

Conservative Therapy Prior to Percutaneous/Endoscopic Procedures

The stepwise approach to conservative therapy before percutaneous or endoscopic lumbar procedures is supported by study inclusion criteria; ensure records reflect trials of conservative care consistent with those criteria.

List conservative treatments, durations, and objective measures of failure.
Align documentation with study-based thresholds when applicable (e.g., minimum months of symptoms).

Denial Risk

Reoperation Risk May Trigger Coverage Scrutiny

High rates of reoperation or recurrent pathology reported for some percutaneous procedures may trigger closer coverage scrutiny and affect medical necessity determinations. Ensure documentation addresses risk–benefit considerations and expected durability of benefit.

Report prior surgeries at the index level and any factors increasing reoperation risk.
Include informed consent discussion addressing recurrence and reoperation likelihood.

Denial Risk

Evidence-Related Denial Risk

Low-quality, mixed, or biased evidence for certain minimally invasive spine procedures may lead to denial of coverage. Provide high-quality supporting documentation when requesting coverage for procedures with limited evidence.

Be aware that insufficient evidence may result in non-supportive coverage determinations.
Supplement requests with peer-reviewed evidence, registries, and long-term outcome data when available.

Note

Plan-Specific Coverage Governs

Coverage determinations are governed by the member's federal, state, or contractual plan terms. This Medical Policy is guidance; in the event of a conflict, the plan's benefit documents and applicable laws take precedence.

Verify the member's specific benefit plan and applicable federal/state mandates before authorizing services.
UnitedHealthcare may use third-party tools (e.g., InterQual) to assist in benefit administration.

Presacral/transaxial (paracoccygeal) approach along the long axis of the spine through a small incision adjacent to the tailbone.

Outcomes/evidence noteRetrospective series report acceptable pain and function improvements and variable fusion rates; postmarketing surveillance (9,152 individuals) reported an overall 1.3% complication rate (policy discussion).

Percutaneous Endoscopic Lumbar Discectomy (PELD)

DefinitionPercutaneous Endoscopic Lumbar Discectomy (PELD): A minimally invasive endoscopic procedure that removes herniated disc material using a small linear skin incision and an advanced camera (endoscope) to magnify the operative field and protect neural structures.

Technique featuresUses endoscopic visualization and instrumentation through a small incision with camera magnification for direct visualization.

Evidence summarySystematic reviews/meta-analyses report similar functional outcomes to open discectomy in many studies, with advantages in incision size, blood loss, and length of stay but some analyses show higher recurrence rates; larger RCTs needed.

MILD (Image-Guided Minimally Invasive Lumbar Decompression)

DefinitionMILD (Image-Guided Minimally Invasive Lumbar Decompression): An image-guided, minimally invasive procedure to decompress the lumbar spine for central canal stenosis caused by hypertrophied ligamentum flavum.

Typical indicationCentral lumbar spinal stenosis due to thickened ligamentum flavum manifesting with neurogenic claudication.

Evidence summaryRandomized trials and consensus guidelines report short- to mid-term improvements; evidence quality ranges from low to moderate with need for longer-term comparative data.

PILD (Percutaneous Image-Guided Lumbar Decompression)

DefinitionPILD (Percutaneous Image-Guided Lumbar Decompression): A percutaneous, image-guided procedure that removes thickened tissue to enlarge the spinal canal and relieve nerve compression; performed without direct visualization.

Relation to MILDOften referred to interchangeably with MILD® in the policy; both are image-guided percutaneous decompression techniques for central stenosis due to ligamentum flavum hypertrophy.

Evidence summaryRCTs and systematic reviews show short- to mid-term symptom and function improvements in selected patients, but long-term durability and comparative effectiveness versus open decompression remain uncertain.

Sacroplasty

DefinitionSacroplasty: Percutaneous placement of polymethyl methacrylate cement into a sacral insufficiency fracture to provide mechanical stabilization and pain relief; can be performed via multiple approaches including bilateral short/long axis, transiliac, and balloon-assisted techniques.

Supported indicationsSystematic review/meta-analysis reports high technical (98.9%) and clinical (95.7%) success for osteoporotic or malignant sacral fractures with sustained pain reduction up to 12 months.

LimitationsEvidence is insufficient and low-quality for sacroplasty when SIFs are due to causes other than osteoporosis or malignancy; further research recommended.

AxiaLIF (alternate reference)

DefinitionAxiaLIF (alternate description): A minimally invasive presacral axial lumbar interbody fusion technique for L5–S1 (and occasionally L4–S1) using a transaxial presacral approach with small incisions adjacent to the coccyx for disc removal, bone graft placement, and supplemental instrumentation.

Clinical findingsRetrospective series report pain and function improvements and variable fusion rates (e.g., complete fusion ~65% in one series); a large postmarketing surveillance (9,152 individuals) reported a 1.3% overall complication rate.

Evidence limitationsAvailable evidence is largely retrospective and nonrandomized; comparative studies show higher pseudarthrosis and some increased complication rates versus alternative fusion approaches.

MILD / PILD (alternate refs)

DefinitionMILD / PILD (alternate description): Minimally invasive lumbar decompression (mild®) performed percutaneously under image guidance to treat central lumbar spinal stenosis primarily due to hypertrophied ligamentum flavum; removes small volumes of tissue to enlarge the canal.

Guideline positionConsensus guidelines and randomized trials have supported PILD/MILD for selected patients, but recommend additional high-quality and longer-term comparative studies.

Clinical implicationTypically considered after failure of conservative therapy in appropriately selected patients; document prior conservative management when requesting authorization.

PLDD (Percutaneous Laser Disc Decompression)

DefinitionPLDD (Percutaneous Laser Disc Decompression): A percutaneous technique using laser energy to ablate or decompress nucleus pulposus material to reduce disc volume and radicular symptoms.

Evidence concernsRandomized and observational studies report mixed evidence with notably higher reoperation/resurgery rates in some trials (e.g., 38% reoperation in a noninferiority RCT; 26% in a retrospective series), raising uncertainty about its role as a replacement for open discectomy.

Clinical noteShort-term symptomatic improvements reported in some cohorts, but high early reoperation rates suggest careful patient selection and consideration against standard open techniques.

Laparoscopic ALIF (LALIF/R-ALIF)

DefinitionLaparoscopic ALIF (LALIF/R-ALIF): Minimally invasive or robotic-assisted anterior lumbar interbody fusion approaches using small abdominal incisions or robotic systems to access the anterior spine for interbody fusion.

Evidence summaryLiterature is largely older case series and nonrandomized studies; LALIF shows similar outcomes to mini-open ALIF but with longer operative times and potentially higher complication rates; R-ALIF early data are limited but suggest possible advantages with additional logistical and training barriers.

Current useLALIF is now rarely used based on recent reviews; further high-quality studies are needed to clarify long-term benefits and risks.

PELD / Percutaneous Endoscopic Lumbar Discectomy (alternate)

DefinitionPELD / Percutaneous Endoscopic Lumbar Discectomy (alternate): A minimally invasive endoscopic technique to remove herniated disc material via a small incision using an endoscope for direct visualization and neural protection.

Comparative evidenceMeta-analyses and systematic reviews report comparable mid- and long-term clinical efficacy to microendoscopic or open discectomy, with advantages in incision size and hospital stay, but heterogeneity and limited randomized data warrant further trials.

RecommendationLarge, well-designed randomized trials with long-term follow-up are needed to confirm durability and recurrence risk profiles.

PLDD / Percutaneous Lumbar Disc Decompression (alternate)

DefinitionPLDD / Percutaneous Lumbar Disc Decompression (e.g., Dekompressor): Image-guided percutaneous mechanical decompression of the disc nucleus intended to reduce intradiscal pressure and radicular symptoms.

Outcomes/evidenceObservational cohorts report initial symptomatic improvement (short-term success ~67%) but variable long-term durability with substantial reoperation rates (e.g., 26% in one retrospective series); lack of randomized comparative trials limits conclusions.

Clinical implicationGiven mixed long-term outcomes and higher reoperation rates in some reports, PLDD should not be assumed equivalent to open discectomy without stronger comparative evidence.

Sacroplasty (alternate)

DefinitionSacroplasty (alternate): Percutaneous cement augmentation of sacral insufficiency fractures using polymethyl methacrylate to stabilize fracture and relieve pain; multiple approach options exist including balloon-assisted techniques.

Supported useSystematic review/meta-analysis demonstrates high technical (98.9%) and clinical (95.7%) success for osteoporotic or malignant sacral fractures with sustained pain reduction up to 12 months.

LimitationsInsufficient and low-quality evidence for sacroplasty when SIFs arise from non-osteoporotic/non-malignant causes; further RCTs recommended.

Transforaminal Lumbar Interbody Fusion (TLIF) — added definition

Definition addedTransforaminal Lumbar Interbody Fusion (TLIF): Definition added to the policy (03/01/2026) to describe the transforaminal approach for lumbar interbody fusion; exact policy text updated in Definitions section.

Evidence contextSystematic reviews/meta-analyses in the supporting evidence compare endoscopic/biportal/percutaneous fusion techniques with MIS-TLIF and PLIF; findings are limited by study heterogeneity and small sample sizes.

Operational impactAddition of TLIF definition reflects policy updates and may affect documentation expectations when TLIF techniques are requested for coverage decisions.

Transforaminal Lumbar Interbody Fusion — additional reference

Duplicate noticeTransforaminal Lumbar Interbody Fusion (TLIF): Policy contains additional references and evidence summaries related to TLIF and endoscopic/minimally invasive fusion techniques in the Clinical Evidence and References sections (updated 03/01/2026).

Research summaryMeta-analyses of Endo-LIF/Endo-TLIF/PE-TLIF/BE-LIF versus MIS-TLIF/PLIF report similar complication, reoperation, and fusion rates with some early recovery advantages but overall limited by low-quality evidence.

Provider implicationDocument indication and rationale for TLIF technique selection; guideline updates note no conclusive evidence to prefer one TLIF technique over another.

Definitions removed or updated

Definitions removedDefinitions removed from the policy include: Interlaminar Lumbar Instrumented Fusion (ILIF); Nucleoplasty; Percutaneous or Endoscopic Lumbar Fusion (Transforaminal TESSYS® and interlaminar endoscopic systems); and Tubular Retractor.

RationalePolicy History indicates these definitions were removed or updated as part of the 03/01/2026 revision.

Action for usersWhen requesting coverage or documenting procedures, use the current, updated policy definitions and exclude terms removed from the Definitions section.

Supporting content updates

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