Minimally Invasive Spine Surgery Procedures (for Tennessee Only)
This policy governs coverage determinations for specific minimally invasive spine surgery procedures for Tennessee Medicaid and CoverKids members, describing which procedures are considered unproven or not medically necessary and providing related definitions and coding.
Policy Summary
PayerUnitedHealthcare
PolicyMinimally Invasive Spine Surgery Procedures (for Tennessee Only)
Key ActionVerify and use the updated applicable CPT code list when requesting prior authorization and include required clinical documentation (indication, prior conservative therapy, and objective outcome measures).
Added definition of 'Transforaminal Lumbar Interbody Fusion'.
Updated list of applicable CPT codes to reflect annual edits, including addition of 62330 and 62331 and removal of 0275T; revised description for 62287.
Removed definition of Interlaminar Lumbar Instrumented Fusion (ILIF), Nucleoplasty, Percutaneous or Endoscopic Lumbar Fusion, Transforaminal (TESSYS ® ) and Interlaminar Endoscopic Surgical Systems, and Tubular Retractor.
Removed CPT code 0275T from the applicable codes list.
9procedures listed as unproven / not medically necessary
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2CPT codes added
1CPT codes removed
Coverage Determinations
Unproven / Not Medically Necessary
The following spinal procedures are unproven and not medically necessary due to insufficient evidence of efficacy:
Unproven/Not Medically Necessary Procedures: Axial Lumbar Interbody Fusion (AxiaLIF) — presacral L5–S1 approach; Percutaneous Image-Guided Lumbar Decompression (PILD); Percutaneous sacral augmentation (Sacroplasty), with or without balloon or bone cement; Automated Percutaneous Lumbar Discectomy (APLD); Percutaneous Endoscopic Lumbar Discectomy (PELD); Minimally Invasive Lumbar Decompression (MILD); Laparoscopic Anterior Lumbar Interbody Fusion (LALIF); Transforaminal Lumbar Interbody Fusion (TLIF) when using only endoscopic visualization (percutaneous incision with video visualization).
These procedures are listed as unproven/not medically necessary by the policy.
Procedure-specific coverage considerations
Coverage considerations based on available evidence and guideline statements:
AxiaLIF (axial presacral fusion): Evidence includes retrospective cohorts and postmarketing surveillance showing variable fusion rates and clinical improvement in some series, but comparative nonrandomized data report higher pseudarthrosis, major complication, and revision rates versus ALIF; NICE recommends use only with special arrangements (governance, consent, audit, or research).evidence limited; small sample sizes and nonrandomized designs
See retrospective series, postmarketing surveillance, and NICE guidance.
Laparoscopic ALIF and robotic-assisted ALIF: Published literature is primarily older case series and nonrandomized comparative studies with heterogeneity; current evidence does not permit strong conclusions that LALIF or R‑ALIF are routinely superior to open approaches and long‑term benefit is uncertain.insufficient high-quality evidence to favor routinely over open approaches
Available studies are small, often outdated, and methodologically limited.
MILD / PILD (percutaneous image-guided lumbar decompression): Randomized trials and systematic reviews report short‑ to mid‑term improvements in symptoms and function for patients with central stenosis due to hypertrophied ligamentum flavum, but trials are limited by risk of bias and uncertainty about long‑term durability and comparison with open decompression.evidence supportive for selected patients with hypertrophied ligamentum flavum; most trials included prior conservative therapy
Consensus guidelines (Deer et al., 2019) rated evidence favorably but HTA reviews (Hayes) judged overall evidence low quality and uncertain for long‑term outcomes.
Percutaneous laser disc decompression (PLDD) and mechanical decompression devices: Evidence is limited and of low quality; RCT data suggest similar short‑term outcomes but substantially higher reoperation rates compared with conventional surgery in some trials, raising concerns about long‑term effectiveness.uncertain long-term benefit and higher reoperation risk
Noninferiority RCT showed higher reoperation (38% vs 16%); observational series report resurgery rates up to 26%.
Coverage considerations and evidence caveats
Summary of evidence-to-coverage considerations drawn from the document excerpts:
General evidence limitations: Most percutaneous, endoscopic, and other minimally invasive spine procedures in this policy rely on observational studies, small RCTs, or meta‑analyses with heterogeneity; high‑quality, multicenter RCTs with long‑term follow‑up are generally lacking.
Additional large, well‑designed RCTs recommended.
When percutaneous/endoscopic decompression or discectomy may be considered: May be considered after failure of conservative management and when patient selection matches studied populations (for example, symptomatic lumbar disc herniation or central stenosis due to ligamentum flavum hypertrophy); document prior conservative therapy and symptom duration (minimum 3 months reported in some series).minimum 3 months of symptoms referenced in at least one series
Conservative therapy attempts and duration should be documented.
Concerns requiring explicit discussion/authorization: Higher recurrence or reoperation rates have been reported for some techniques (examples: 38% reoperation after percutaneous laser disc decompression in an RCT; pooled recurrence 7.57% with PELD vs 4.38% with comparators; 26% resurgery in a PLDD series), which should be disclosed to patients and considered during authorization and selection processes.
Evidence-based coverage considerations
Summarized evidence-based coverage considerations
Comparative effectiveness and perioperative outcomes: Systematic reviews and pooled analyses comparing endoscopic or percutaneous interbody and decompression techniques (Endo‑LIF, PE‑TLIF, Endo‑TLIF, biportal/endoscopic TLIF variants) with MIS‑TLIF or open TLIF generally report similar fusion, complication, and reoperation rates, with potential perioperative advantages (less blood loss, shorter hospital stay, faster early recovery) but often longer operative times for endoscopic approaches.
Findings based on small studies and meta‑analyses with methodological limitations.
Evidence quality and follow-up limitations: Available comparative studies are frequently nonrandomized, retrospective, single‑center, and have short to medium follow‑up; statistical heterogeneity and risk of bias limit confidence in pooled estimates and long‑term outcomes remain uncertain.
RCTs with longer follow‑up are needed to confirm comparative effectiveness.
Clinical outcome measures used in evidence: Key outcomes reported across studies include VAS for back and leg pain, ODI (or JOA) functional scores, fusion rates, operative time, intraoperative blood loss, time to ambulation, length of hospital stay, complications, and reoperation rates; these outcomes are relevant for coverage assessments and documentation expectations.
The inclusion of a CPT, HCPCS, or other procedure code in this policy is for reference only and does not imply that the service described by the code is a covered or non‑covered health service. Benefit coverage and reimbursement are governed by the member's applicable federal, state, or contractual benefit terms and any applicable laws; those terms control in the event of a conflict. Providers should not assume listing equates to authorization or payment and should verify coverage against the member's plan and contractual requirements when submitting claims or prior authorization requests.
Clinical guideline guidance should inform, but not supplant, individualized clinical decision‑making. Per the AANS/CNS guideline on lumbar fusion for degenerative disease, lumbar fusion is not recommended for isolated lumbar stenosis in the absence of deformity or instability. When there is no deformity or mechanical instability, fusion has not been shown to improve outcomes over decompression alone and therefore should not be routinely performed for isolated stenosis.
Evidence for percutaneous sacroplasty varies by fracture etiology. While sacroplasty has been evaluated for osteoporotic or malignant sacral insufficiency fractures, the literature is sparse and of low quality for sacral insufficiency fractures from causes other than osteoporosis or malignancy. For SIFs not due to osteoporosis or malignancy, available data are insufficient to establish safety and durable clinical benefit, and such cases should be considered for exclusion or limitation pending higher‑quality evidence.
Coverage determinations may exclude procedures or device claims that are supported solely by low‑quality evidence or studies at high risk of bias. When the body of evidence consists primarily of nonrandomized comparisons, small case series, or studies with methodological limitations and no robust comparative data, those requests may be denied or require additional justification because they do not demonstrate adequate evidence of net health benefit.
This policy provides interpretive guidance only; providers must consult the member's specific benefit plan. Federal, state, or contractual benefit terms govern the determination of coverage and prevail if there is any conflict with this policy. Providers should confirm applicable plan requirements and any regulatory mandates before proceeding with treatment or billing decisions.
The policy identifies a set of specific minimally invasive spinal procedures as unproven or not medically necessary based on the available evidence. These include Axial Lumbar Interbody Fusion (AxiaLIF), Percutaneous Image‑Guided Lumbar Decompression (PILD), percutaneous sacral augmentation (sacroplasty) with or without balloon or cement, Automated Percutaneous Lumbar Discectomy (APLD), Percutaneous Endoscopic Lumbar Discectomy (PELD), Minimally Invasive Lumbar Decompression (MILD), Laparoscopic Anterior Lumbar Interbody Fusion (LALIF), and TLIF performed using only endoscopic visualization. Because the evidence for these procedures is limited or of low quality, claims for these services are at risk for denial absent compelling patient‑specific justification and supporting documentation.
For percutaneous image‑guided lumbar decompression procedures (PILD/mild), the literature includes randomized and nonrandomized studies showing symptomatic improvement in selected patients, but trials have methodological limitations and risk of bias. The available evidence is insufficient to determine efficacy compared with placebo or to definitively establish equivalence with open decompression, and uncertainty about long‑term durability remains. This limitation supports cautious consideration and documentation when requesting coverage for PILD.
Percutaneous laser disc decompression (PLDD) and similar percutaneous discectomy techniques have shown notable resurgery and reoperation rates in some studies. For example, an RCT reported a 38% reoperation rate after percutaneous laser disc decompression versus 16% after conventional surgery, and observational series have reported resurgery rates around 26%. These outcomes highlight evidence limitations and the need to document prior conservative care and patient selection when PLDD is proposed.
Pooled analyses and meta‑analyses of percutaneous endoscopic lumbar discectomy (PELD) indicate similar overall success rates compared with other surgical techniques but have reported a higher rate of recurrent disc herniation in some studies. For example, recurrence rates reported in a meta‑analysis were 7.57% for PELD versus 4.38% for comparator surgeries, suggesting increased risk of recurrent herniation that should be considered when evaluating requests for PELD.
Many emerging endoscopic and minimally invasive fusion or repair techniques lack large, well‑designed randomized comparative trials. Published evidence is often limited to case series, retrospective comparisons, and small trials, which restricts confidence in comparative effectiveness and long‑term outcomes. When such interventions are proposed without adequate comparative evidence, coverage determinations may not be supported until higher‑quality data are available.
Although the policy lists multiple procedures as unproven or not medically necessary based on the evidence review, the document does not include standalone administrative language declaring services universally not medically necessary beyond the evidence‑based statements. In all cases, coverage decisions must be made in the context of the member's federal, state, or contractual benefit terms, which govern when there is any discrepancy between policy guidance and plan requirements.
Applicable Procedure and Billing Codes
Applicable Procedure Codes (reference)CPT
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 / Othermixed
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.
Updated Applicable CPT Codes (high-level list of edits)CPT
62330
Added to applicable CPT codes
62331
Added to applicable CPT codes
0275T
Removed from applicable CPT codes
62287
Description revised
Applicable CPT code edits (annual update)CPT
62330
Added to applicable CPT codes
62331
Added to applicable CPT codes
0275T
Removed from applicable CPT codes
62287
Description revised
Provider Requirements and Authorization Guidance
Prior Authorization
Provider Requirements and Authorization Guidance
The following actionable provider requirements and authorization guidance apply. Providers must verify member benefit terms and applicable codes when requesting authorization; inclusion of a code in this policy is reference only and does not guarantee coverage or payment.
Applicable Codes listed in this policy are provided for reference only — listing does not imply coverage or guarantee reimbursement. Verify federal/state/contractual plan terms and member benefits prior to billing or requesting authorization.
Prior authorization is recommended for procedures with limited or low-quality evidence (for example: AxiaLIF, PILD/MILD, sacroplasty, PLDD, laparoscopic ALIF, percutaneous/laser decompression, endoscopic-only TLIF). When requesting prior authorization for these procedures document the clinical rationale and supporting evidence.
For endoscopic discectomy (PELD/other endoscopic techniques), include a comparative justification in the authorization request explaining why endoscopic approach is preferred over standard open or microdiscectomy, and supply available outcome data or literature when possible.
Providers should confirm the current CPT/HCPCS/ICD-10 codes applicable to the requested service at time of authorization and claims submission — the policy’s Applicable Codes list is not exhaustive.
Consult member-specific benefit plans and utilization management tools (including any InterQual or third-party criteria used by UnitedHealthcare) prior to scheduling procedures.
Clinical Background and Context
Low back pain and radiculopathy related to herniated intervertebral discs are common conditions that frequently improve with nonoperative management. Conservative care (for example, activity modification, physical therapy, and analgesic management) is the usual initial approach, and surgical decompression is typically reserved for patients with persistent, functionally limiting or neuropathic symptoms despite adequate conservative treatment. Documenting prior conservative therapy and symptom duration is expected when considering minimally invasive or surgical interventions.
DefinitionPercutaneous removal of protruding disc material using a large-bore needle inserted directly into the disc space (Automated Percutaneous Lumbar Discectomy, APLD).
Typical indicationTreatment of symptomatic lumbar disc herniation with protruding disc material when considered by the treating clinician.
Key characteristicNeedle-based, percutaneous technique performed under imaging guidance; described by NASS (2025).
DefinitionMinimally invasive presacral (trans-sacral/transaxial/paracoccygeal) interbody fusion technique used for L5–S1 (Axial Lumbar Interbody Fusion, AxiaLIF) providing access along the long axis of the spine via a presacral approach.
Evidence summary
Policy Changes and Update Log
2026-03-01definitions_updateLatest
Added definition of 'Transforaminal Lumbar Interbody Fusion' and removed multiple legacy definitions (Interlaminar Lumbar Instrumented Fusion, Nucleoplasty, Percutaneous or Endoscopic Lumbar Fusion, TESSYS and interlaminar endoscopic systems, and Tubular Retractor); updated several existing definitions (APLD, AxiaLIF, Endoscope, Endoscopic Discectomy, Fluoroscopy, MILD®, Interbody Fusion, LALIF, Open Spine Surgery, PELD, PILD, Posterior Lumbar Spine Surgery, Sacroplasty).
2026-03-01coding_update
Updated applicable CPT code list to reflect annual edits: added CPT codes 62330 and 62331, removed CPT code 0275T, and revised the description for CPT 62287.
Policy Summary
PayerUnitedHealthcare
PolicyMinimally Invasive Spine Surgery Procedures (for Tennessee Only)
Key ActionVerify and use the updated applicable CPT code list when requesting prior authorization and include required clinical documentation (indication, prior conservative therapy, and objective outcome measures).
May necessitate enhanced consent, careful patient selection, and justification for use.
Sacroplasty evidence caveat: For sacral insufficiency fractures due to osteoporosis or malignancy, meta‑analyses report high technical and clinical success but randomized trials are lacking; for SIFs from other etiologies evidence is minimal and insufficient to establish safety and efficacy.
Differentiate fracture etiology when evaluating coverage.
Objective reporting of these measures supports evaluation of clinical benefit and durability.
Claims for procedures identified in this policy as unproven or not medically necessary may be denied; submit thorough documentation if requesting exception/medical review.
High reoperation/resurgery rates reported for some procedures (eg, PLDD/percutaneous laser decompression) may affect authorization and coverage determinations; disclose prior surgeries and known reoperation risks in requests.
Low-quality evidence, small studies, high risk of bias, heterogeneity, or other evidence limitations described in the policy may lead to noncoverage or denial decisions; provide high-quality, procedure-specific evidence when available.
Conservative management (eg, physical therapy, activity modification, medication, epidural steroid injections as appropriate) is the usual initial approach for most lumbar conditions and is generally expected prior to surgical decompression or minimally invasive interventions.
Trials of conservative therapy are commonly expected prior to interventions such as MILD/PILD and other minimally invasive lumbar procedures; document duration, modalities tried, and response to therapy.
When prior conservative management is a prerequisite for authorization, clearly document the conservative therapies used, dates/duration, and objective clinical response in the medical record and attach to the prior authorization request.
Documentation Required
Recommended Clinical Documentation
Recommended documentation to support medical necessity and authorization requests.
Presenting indication, relevant clinical history, and physical examination findings.
Pertinent imaging reports (MRI, CT) that demonstrate the anatomic lesion targeted by the proposed procedure.
Documentation of prior conservative care: modalities, dates, duration, and clinical response (eg, PT, medications, injections).
Operative reports for prior spine procedures, and descriptions of prior surgeries and outcomes.
For endoscopic fusion or MIS fusion requests (eg, Endo-TLIF, MIS-TLIF), include operative report, intraoperative findings, and follow-up demonstrating fusion or reasons fusion is expected to improve outcomes.
For PLDD, PELD, or other percutaneous decompression requests include symptom duration, neurologic exam findings, prior treatments, and rationale that less invasive standard options are not appropriate.
If requesting coverage for procedures with limited evidence, include peer-reviewed literature, outcomes data, and explanation for patient-specific clinical reason the procedure is indicated.
Any relevant functional measures (ODI, VAS) and previous response to conservative treatments.
Retrospective cohorts report clinical improvement and variable fusion rates (e.g., Balsano et al. 52 patients; Zeilstra et al. 131 patients); postmarketing surveillance (Gundanna et al.) identified rare but serious complications.
Guidance noteNICE recommends use only with special arrangements for governance, consent, audit, or research due to recognized serious complications.
DefinitionMinimally invasive procedure for lumbar disc herniation using a linear skin incision and endoscopic camera system to visualize and remove herniated disc material (Percutaneous Endoscopic Lumbar Discectomy, PELD).
Evidence noteMeta-analyses and systematic reviews report similar short-term outcomes to open techniques but a higher rate of recurrent disc herniation in pooled analyses (recurrence 7.57% vs 4.38% in comparators).
Clinical implicationLarge, well-designed randomized trials with long-term follow-up are needed to establish comparative safety and efficacy versus open discectomy.
DefinitionMinimally invasive image-guided percutaneous procedure to remove thickened tissue (eg, hypertrophied ligamentum flavum) to enlarge the spinal canal and relieve nerve compression (Percutaneous Image-Guided Lumbar Decompression, PILD; includes MILD ® technique).
Evidence summaryRCTs, cohort studies, and consensus guidelines report short- to mid-term symptom and functional improvement in select patients, but long-term durability and comparative effectiveness versus open decompression remain uncertain (Hayes HTA; Deer et al. guideline).
Documentation expectationTrials in the literature generally included prior conservative therapy; document conservative management attempts and symptom duration when considering PILD.
Sacroplasty — definition entry
DefinitionMinimally invasive placement of polymethyl methacrylate cement into a sacral insufficiency fracture via multiple possible approaches, with or without balloon assistance (Sacroplasty).
Evidence nuanceMeta-analysis reports high technical (98.9%) and clinical (95.7%) success for osteoporotic or malignant sacral fractures, but evidence is insufficient/low-quality for SIFs due to causes other than osteoporosis or malignancy.
Coverage considerationDifferentiate fracture etiology (osteoporotic/malignant vs other causes) when evaluating evidence and coverage decisions; larger RCTs are recommended for nonosteoporotic etiologies.
DefinitionMinimally invasive presacral axial lumbar interbody fusion technique for L5–S1 (and occasionally L4–S1) that achieves fusion via a transaxial presacral approach (AxiaLIF).
Study examplesReported series include small retrospective cohorts with follow-up assessing VAS and ODI and radiographic fusion (eg, Balsano et al.).
Safety notePostmarketing surveillance and guideline guidance highlight rare but serious complications and recommend special governance or research settings for use.
DefinitionMinimally invasive percutaneous image-guided lumbar decompression (MILD ® /PILD) intended to treat central canal narrowing from hypertrophied ligamentum flavum using a proprietary kit and performed under fluoroscopic/image guidance.
Evidence summarySystematic reviews and RCTs included in consensus guidance report symptom and functional improvements up to 1–2 years with low reported adverse event rates (eg, pooled adverse event rate ~8.2% in meta-analysis), but long-term comparative efficacy is uncertain.
Clinical pathwayTrials generally included prior conservative therapy; document prior conservative treatments and durations when considering the procedure.
DefinitionPercutaneous laser disc decompression (PLDD) is a minimally invasive procedure that uses laser energy to reduce disc material volume to relieve radicular symptoms.
Outcomes cautionRCTs and observational studies report higher reoperation/resurgery rates with PLDD compared with conventional surgery (eg, Brouwer et al. reported 38% vs 16% reoperation), raising concerns about long-term benefit.
Selection noteSome series mandated a minimum symptom duration (eg, 3 months) and excluded prior lumbar surgery; document indication and prior treatments in submissions.
DefinitionPercutaneous lumbar disc decompression using a mechanical device (eg, the Dekompressor) intended to reduce disc volume and relieve radicular symptoms via a percutaneous approach (mechanical decompression / PLDD alternative).
Evidence noteObservational series report initial short-term success but notable resurgery rates (eg, Klessinger reported 26% subsequent open surgery after Dekompressor PLDD), which may offset early benefits.
Documentation expectationClinical records should document symptom duration, exclusion of prior lumbar surgery where applicable, and rationale for percutaneous approach given variable reoperation rates.
DefinitionPercutaneous Endoscopic Lumbar Discectomy (PELD) — minimally invasive endoscopic removal of herniated disc material via a small incision and endoscopic visualization.
Evidence cautionMeta-analyses indicate similar short-term efficacy to other techniques but an increased rate of recurrent herniation (eg, pooled recurrence 7.57% vs 4.38% in comparators), necessitating careful patient selection and counseling.
Research needLarge, blinded RCTs with long-term follow-up are needed to determine comparative effectiveness and durability versus open discectomy.
Sacroplasty — percutaneous augmentation definition (evidence varies by etiology)
DefinitionPercutaneous augmentation of sacral insufficiency fractures with bone cement (polymethyl methacrylate), performed via multiple approaches with or without balloon assistance (sacroplasty).
Evidence variabilitySystematic reviews report high technical and clinical success for osteoporotic or malignant sacral fractures (technical success 98.9%, clinical success 95.7%), but evidence is insufficient/low quality for fractures from other causes.
Coverage considerationDifferentiate sacral fracture etiology when assessing value; RCTs comparing sacroplasty with conservative management or sham procedures are lacking.
Transforaminal Lumbar Interbody Fusion — new definition added to policy
DefinitionTransforaminal Lumbar Interbody Fusion (TLIF) — a modification of posterior lumbar interbody fusion approaching the intervertebral body from a transforaminal route, removing the disc and placing bone graft through that route; added to the policy Definitions section.
ContextDefinition was added in the 03/01/2026 policy revision and supports inclusion of endoscopic and percutaneous variants in discussion of interbody fusion techniques.
Evidence noteComparative meta-analyses of endoscopic/PE-TLIF vs MIS-TLIF report similar complication, fusion, and reoperation rates but are limited by small studies and heterogeneity; further RCTs are needed.
Definitions updated — note that multiple definitions were updated or removed in this revision
SummaryDefinitions were updated in the 03/01/2026 revision: multiple definitions were revised (APLD, AxiaLIF, Endoscope, Endoscopic Discectomy, Fluoroscopy, MILD ® /PILD, Interbody Fusion, LALIF, Open Spine Surgery, PELD, PILD, Posterior Lumbar Spine Surgery, Sacroplasty) and several definitions were removed (eg, ILIF, Nucleoplasty, Percutaneous/Endoscopic Lumbar Fusion, TESSYS ® systems, Tubular Retractor).
Operational impactPolicy history notes additions/removals of definitions and annual CPT code edits; providers should refer to the updated Definitions section and applicable codes when applying the policy.
ActionVerify the policy's current Definitions and Applicable Codes (revision effective 03/01/2026) when preparing documentation or prior authorization requests.
2026-03-01supporting_information_update
Revised the Description of Services, Clinical Evidence, and References sections to reflect current information.