DraftUnitedHealthcarePolicy CSNCT0365.04

Spinal Fusion and Decompression (for North Carolina Only)

Coverage and coding guidance for spinal fusion and decompression procedures for UnitedHealthcare members in North Carolina; defers medical necessity determinations to North Carolina Medicaid Clinical Coverage Policy Physician: 1A-30.

Policy Summary

PayerUnitedHealthcare

PolicySpinal Fusion and Decompression (for North Carolina Only)

Policy CodePolicy CSNCT0365.04

Change TypeCodes flagged for NC Medicaid fee schedulerelated-policy link updates

Effective DateFeb 1, 2025

Next Review Date

Key ActionFollow North Carolina Medicaid Clinical Coverage Policy Physician: 1A-30 for prior authorization and medical necessity determinations.

SourceLink

POLICY UPDATE CHANGES

Added notation that CPT codes 0179T, 0202T, 0219T, 0220T, 0221T, 0222T, 63052, and 63053 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 to reflect current policy titles for several related policies (Discogenic Pain Treatment; Vertebral Body Tethering for Scoliosis; Spinal Fusion and Bone Healing Enhancement Products).

20+CPT/HCPCS codes listed

NC onlyapplicability

NC Medicaid 1A-30medical necessity cross-reference

8 codes

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Coverage Criteria and Applicability

Medical necessity delegation

Covered when ALL of the following are met:

Primary rule: Medical necessity clinical coverage criteria are determined 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 detailed clinical criteria.

The list of procedure and diagnosis codes in this policy is provided for reference only. Listing a code does not imply the service described by the code is a covered or non-covered health service, nor does it guarantee reimbursement or payment. Benefit coverage is determined by applicable federal, state, and contractual requirements and laws, and other UnitedHealthcare policies and clinical guidelines may apply.

Certain CPT codes identified in this policy are annotated as not appearing on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program. Providers should note these exclusions when submitting claims and when requesting prior authorization; see the code list and the Policy History for the specific CPTs flagged.

This document does not itself enumerate specific conditions that are classified as not medically necessary. Medical necessity determinations and any associated limitations are governed by the applicable federal, state, or contractual requirements referenced in this policy — for North Carolina, clinical coverage criteria are determined by the North Carolina Medicaid Clinical Coverage Policy (Physician: 1A-30).

Procedure and Billing Codes

Selected HCPCS/CPT Category III and category II examplesmixed

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.

Applicable CPT Codes (spine fusion/decompression and related procedures)CPT

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.
22551	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2.
22630	Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar.
22800	Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments.
22830	Exploration of spinal fusion.
22840	Posterior non-segmental instrumentation (e.g., Harrington rod technique, pedicle fixation across 1 interspace).
22842	Posterior segmental instrumentation; 3 to 6 vertebral segments.
22853	Insertion of interbody biomechanical device(s) with integral anterior instrumentation, each interspace.
22899	Unlisted procedure, spine.

1–10 of 16

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Applicable CPT Codes - LaminectomyCPT

63272	Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar.
63275	Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical.
63277	Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar.
63280	Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, cervical.
63282	Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar.
63285	Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical.
63286	Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracic.
63287	Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracolumbar.

Applicable CPT Codes - Vertebral CorpectomyCPT

63290	Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural lesion, any level.
63300	Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, cervical.
63301	Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by transthoracic approach.
63302	Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by thoracolumbar approach.
63303	Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, lumbar or sacral by transperitoneal or retroperitoneal approach.
63304	Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, cervical.
63305	Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by transthoracic approach.
63306	Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by thoracolumbar approach.
63307	Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal approach.
63308	Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; each additional segment (List separately in addition to codes for single segment).

CPT Codes flagged for NC Medicaid fee scheduleCPT

0179T	Not on the State of North Carolina Medicaid Fee Schedule (notation added).
0202T	Not on the State of North Carolina Medicaid Fee Schedule (notation added).
0219T	Not on the State of North Carolina Medicaid Fee Schedule (notation added).
0220T	Not on the State of North Carolina Medicaid Fee Schedule (notation added).
0221T	Not on the State of North Carolina Medicaid Fee Schedule (notation added).
0222T	Not on the State of North Carolina Medicaid Fee Schedule (notation added).
63052	Not on the State of North Carolina Medicaid Fee Schedule (notation added).
63053	Not on the State of North Carolina Medicaid Fee Schedule (notation added).

State fee schedule exclusion — NC Medicaid (notation *)

State fee schedule exclusionCodes 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.

ScopeApplies to CPT codes annotated with an asterisk in this policy when adjudicating claims or prior authorization for North Carolina Medicaid members.

Operational noteWhen a CPT is flagged as not on the NC Medicaid Fee Schedule, prior authorization and payment decisions should account for possible noncoverage under the State program.

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Must Consider NC Medicaid Fee Schedule Status

Prior authorization decisions must account for the State of North Carolina Medicaid fee schedule status. CPT codes that are not listed on the NC Medicaid Fee Schedule may be excluded from coverage under state Medicaid and could be denied or remain unpaid. When requesting authorization, providers should confirm the member's specific federal, state, and contractual benefit requirements and note any state exclusions that may affect coverage.

Affected codes may include CPTs marked with an asterisk (*) in the Applicable Codes list (e.g., 0179T, 0202T, 0219T, 0220T, 0221T, 0222T, 63052, 63053).
Operational guidance: prior authorization systems and staff must reference NC Medicaid fee schedule status and treat codes not on the fee schedule as potentially non-covered for NC Medicaid members.
In the event of conflict between this policy and federal/state/contractual requirements, the federal/state/contractual requirements govern.

Background and Scope

Background: This policy lists procedures and associated CPT codes related to spinal fusion, decompression, laminectomy, and vertebral corpectomy (for example, codes in the 22200–22899 and 63000–63308 ranges and 63272–63290 series) for administrative and coding reference. Medical necessity for these surgical procedures is determined by North Carolina Medicaid clinical coverage criteria, and inclusion of the procedure codes here does not itself establish coverage or clinical appropriateness.

Definitions and Device References

Laminectomy / Vertebral corpectomy CPT codes

Laminectomy CPT range (examples)63272, 63275, 63277, 63280, 63282, 63285, 63286, 63287 (laminectomy/laminotomy and excision/biopsy of intraspinal lesions).

Additional laminectomy code63290 (combined extradural–intradural lesion, any level).

Vertebral corpectomy CPT range (single segment)63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307 (vertebral corpectomy, single segment; various approaches).

Vertebral corpectomy add-on63308 (each additional segment; list separately in addition to single-segment codes).

TOPS System — motion-preserving spinal implant (FDA PMA)

DeviceTOPS™ System (Premia Spine USA)

Policy Revision History

2025-11-01related_policies_updated

Updated related policy reference links to reflect current policy titles for Discogenic Pain Treatment and Vertebral Body Tethering for Scoliosis (North Carolina only).

2025-10-01related_policies_updated

Updated related policy reference link to reflect current policy title for Spinal Fusion and Bone Healing Enhancement Products (North Carolina only).

2025-02-01codes_flagged_for_nc_medicaidLatest