CurrentUnitedHealthcarePolicy CSNCT0364.03

Minimally Invasive Spine Surgery Procedures (for North Carolina Only)

Policy governing UnitedHealthcare clinical coverage guidance for minimally invasive spine surgery procedures that applies only to North Carolina Medicaid patients; references North Carolina Medicaid Clinical Coverage Policy 1A-30 for medical necessity criteria.

Policy Summary

PayerUnitedHealthcare

PolicyMinimally Invasive Spine Surgery Procedures (for North Carolina Only)

Policy CodePolicy CSNCT0364.03

Change TypeCodes added to NC fee-schedule exclusionrelated policy links updated

Effective DateApr 1, 2025

Next Review Date

Key ActionCheck applicable federal, state, or contractual requirements for prior authorization; UnitedHealthcare may use external tools (e.g., InterQual) to assist in benefit determinations.

SourceLink

POLICY UPDATE CHANGES

Added notation that CPT/HCPCS codes 0200T, 0201T, 0275T, 22899, and G0276 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.

Updated related policy reference links/titles for Discogenic Pain Treatment and Vertebral Body Tethering for Scoliosis.

Updated related policy link/title for Spinal Fusion and Bone Healing Enhancement Products.

Archived previous policy version CSNCT0364.02.

1state governed (North Carolina only)

5+CPT/HCPCS codes not on NC fee schedule

1external policy referenced (1A-30)

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Coverage Criteria

Delegated medical necessity criteria

Medical necessity determinations for coverage:

Primary guidance: Coverage and medical necessity criteria are governed by the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Physician: 1A-30, Spinal Surgeries.

This policy defers to NC Medicaid policy for clinical criteria.

The inclusion of a CPT or HCPCS code in this policy is for reference only and does not imply that the service described by the code is a covered benefit. Benefit coverage and payment entitlement are determined by applicable federal, state, or contractual requirements and laws. The policy notes that codes marked 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, which may result in claim denial or nonpayment.

FDA authorization is provided here for informational purposes only. FDA approval or clearance alone is not a basis for coverage; marketing clearance through the FDA 510(k) process does not guarantee that a device or the procedures using it will be covered under this policy or by applicable benefit plans.

Coding

No codes listed

Note

Provider Notice

Listing of a code does not imply that the service described by the code is a covered or non-covered health service. Providers must reference federal, state, and contract-specific coverage policies, applicable fee schedules, and member benefit documents to determine coverage and reimbursement. Codes marked with an asterisk (*) are not on the State of North Carolina Medicaid Fee Schedule and may not be covered by NC Medicaid. No step therapy requirements are specified in this policy.

Listing of a code does not imply coverage or reimbursement.
These CPT/HCPCS codes are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by NC Medicaid (asterisk-marked codes).
Providers must reference federal, state, and contract-specific coverage policies, applicable fee schedules, and member benefit documents to determine coverage and reimbursement.
No step therapy requirements specified.

Provider Actions and Billing Guidance

Prior Authorization

Confirm prior authorization and benefit rules

Check applicable federal, state, or contractual requirements for prior authorization and benefit coverage before submitting claims; UnitedHealthcare may use external tools (for example, InterQual) to assist in administering benefits.

Step Therapy

No step therapy specified in this policy

There are no step therapy requirements specified in this policy; do not assume step therapy is required without consulting the member’s specific benefit plan and applicable state rules.

Documentation Required

Reference federal/state/contractual benefit requirements

Background

This policy addresses minimally invasive spine surgical procedures such as percutaneous sacral augmentation (sacroplasty), percutaneous laminotomy/laminectomy, percutaneous nucleus pulposus decompression techniques, and endoscopic decompression procedures. It references a range of CPT and HCPCS codes used to describe these techniques and notes that a variety of endoscopes and associated surgical instruments have received FDA marketing clearance through the 510(k) process. Information about specific cleared devices is available from the FDA device database, but device clearance is informational and not determinative of coverage.

Definitions

FDA 510(k) clearance — informational note

DefinitionDevices receiving marketing clearance through the FDA 510(k) process — informational only and not a sole basis for coverage.

Use of informationThis FDA section is for informational purposes only; FDA approval/clearance alone is not a basis for coverage.

Where to verifyRefer to the FDA device database (https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm) and search by product name for details on specific cleared devices.