CurrentUnitedHealthcarePolicy CS365KY.05

Spinal Fusion and Decompression (for Kentucky Only)

UnitedHealthcare Community Plan medical policy for spinal fusion and decompression procedures applicable only to Kentucky members; references InterQual CP for medical necessity, lists unproven/not medically necessary procedures (e.g., dynamic stabilization, facet joint replacement, isolated facet fusion, MOTUS), and details documentation, definitions, codes, FDA/device info, evidence summary, and revision history.

Policy Summary

PayerUnitedHealthcare

PolicySpinal Fusion and Decompression (for Kentucky Only)

Policy CodePolicy CS365KY.05

Change TypeRevisions to coverage rationale, definitions, and applicable codes

Effective DateMay 1, 2026

Next Review Date

Key ActionMedical records must contain documentation that fully supports medical necessity, including relevant history, exam, and diagnostic test results; make records available upon request.

SourceLink

POLICY UPDATE CHANGES

Revised list of unproven and not medically necessary indications (added vertebral joint implants e.g., MOTUS; broadened dynamic stabilization wording; clarified isolated facet joint fusion and facet joint replacement phrasing).

Added definition of 'Facet Joint Replacement'; updated definitions for Dynamic Stabilization, Isolated Facet Joint Fusion, Staged Multiple Sessions, Total Facet Arthroplasty, and Unremitting.

Removed CPT codes 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, and 63265 from Applicable Codes and supporting information; CPT codes 63251, 63252, and 63265 referenced in some summaries as applicable.

Added language clarifying that benefit coverage is determined by federal, state, contractual requirements and that medical records may be required for review and do not guarantee coverage.

Added reference link to the Medical Policy titled Interspinous Fusion and Decompression Devices (for Kentucky Only).

Updated Description of Services, Clinical Evidence, FDA information, and archived previous policy version CS365KY.04.

Coverage Summary

This policy (Spinal Fusion and Decompression (Kentucky); Policy Number CS365KY.05) is effective May 1, 2026 with last review noted May 1, 2026. It applies only to Kentucky members and the document uses InterQual® CP procedure-specific clinical criteria to determine coverage for decompression and fusion procedures. The policy stance is mixed: certain spinal fusion and decompression procedures are covered when InterQual CP criteria are met, while a set of procedures (including Dynamic Stabilization Systems, Facet Joint Replacement, Isolated Facet Joint Fusion, and vertebral joint implants that replace the disc and facet joints such as MOTUS) are listed as unproven and not medically necessary.

Medical Necessity / Coverage Rationale

Coverage Rationale / Medical Necessity

Covered when meeting InterQual CP procedure-specific clinical criteria:

ANY of the following

Decompression +/- Fusion, Cervical (per InterQual CP criteria)
Decompression +/- Fusion, Lumbar (per InterQual CP criteria)
Decompression +/- Fusion, Thoracic (per InterQual CP criteria)
Fusion, Cervical Spine (per InterQual CP criteria)
Fusion, Lumbar Spine (per InterQual CP criteria)
Fusion, Thoracic Spine (per InterQual CP criteria)
Scoliosis or Kyphosis Surgery (per InterQual CP criteria)
Scoliosis or Kyphosis Surgery (Pediatric) (per InterQual CP criteria)

Not Medically Necessary / Unproven

The following procedures are unproven and not medically necessary due to insufficient evidence of efficacy:

ALL of the following

Dynamic Stabilization Systems
Facet Joint Replacement
Isolated Facet Joint Fusion, with or without instrumentation
Vertebral joint implants that replace the disc and facet joints (e.g., MOTUS)

Multiple Serial/Staged Procedures: Dividing treatment of symptomatic, multisite spinal pathology via anterior or posterior approach into serial or Staged Multiple Sessions when one session can address all sites is unproven and not medically necessary

Coding (Applicable and Removed Codes)

Referenced Procedure Codes (Applicable codes; reference only)CPT

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.
0221T	Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar.
0222T	Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; each additional vertebral segment (List separately in addition to code for primary procedure).
0719T	Posterior vertebral joint replacement, including bilateral facetectomy, laminectomy, and radical discectomy, including imaging guidance, lumbar spine, single segment.
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.
22208	Osteotomy of spine, posterior or posterolateral approach, 3 columns, each additional vertebral segment.
22210	Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical.

1–10 of 126

1/13

Removed CPT codesCPTNot Covered

63170
63172
63173
63185
63190
63191
63197
63200
63250
63251

1–10 of 12

1/2

Applicable CPT codes referenced in summariesCPT

63251	CPT code mentioned as applicable in summary
63252	CPT code mentioned as applicable in summary
63265	CPT code mentioned as applicable in summary

Providers should review the policy history for detailed code changes and revisions — the history documents that several CPT codes were removed from the applicable codes/supporting information and that codes 63251, 63252, and 63265 are specifically referenced in revision summaries. Consult the full policy for current billing guidance, updated applicable codes, and prior-authorization instructions.

Provider Actions & Prior Authorization

Prior Authorization

Use InterQual CP criteria for prior authorization determinations

Coverage determinations for spinal decompression and fusion procedures under this policy rely on meeting the InterQual® CP procedure-specific clinical criteria. Prior authorization decisions will use the InterQual CP criteria listed in the policy (Decompression +/- Fusion, Cervical; Decompression +/- Fusion, Lumbar; Decompression +/- Fusion, Thoracic; Fusion, Cervical Spine; Fusion, Lumbar Spine; Fusion, Thoracic Spine; Scoliosis or Kyphosis Surgery; Scoliosis or Kyphosis Surgery (Pediatric)). Providers should also reference applicable state guidelines when preparing prior authorization requests.

Use the InterQual® CP procedure-specific clinical criteria referenced above for prior authorization determinations
Reference state-specific guidelines as applicable

Documentation Required

Medical record documentation required

Background & Evidence Summary

Background: The policy summarizes clinical evidence and regulatory information about motion-preserving and fusion spinal procedures. It references InterQual CP as the primary criteria source for determining medical necessity for decompression and fusion procedures, and provides concise literature summaries for topics including dynamic stabilization (limited controlled trial data and complication/reoperation signals), facet arthroplasty/TOPS (IDE RCT and device assessments), the MOTUS total joint replacement investigational trial (MOTUS TJR), and applicable North American Spine Society guidance. FDA device approvals (for example, TOPS PMA) and device trial results are noted in the supporting sections.

Key Evidence

Devices / Trials

Definitions

Definitions (glossary):

Dynamic Stabilization — Flexible fusion or soft stabilization using motion-preserving, flexible implants (rods, cords, spacers) to stabilize spinal segments (see Definitions section for full text).

Facet Joint Replacement — Replacement of the facet joints (also called total facet arthroplasty) using flexible materials as an alternative to fusion (see Definitions section for full text).

Isolated Facet Joint Fusion — Facet arthrodesis performed without decompression (e.g., fusion of the facet joint using allograft bone dowels).

Staged Multiple Sessions — Procedures performed on different days or requiring an additional anesthesia session.

InterQual — A clinical criteria system used by UnitedHealthcare for primary medical/surgical criteria.

Note: several definitions were updated or removed in policy history (including Dynamic Stabilization, Isolated Facet Joint Fusion, Staged Multiple Sessions, Facet Joint Replacement, Total Facet Arthroplasty, and Unremitting). Providers should reference the policy history and the full policy Definitions section for the exact, current definition wording.

Revision History

05/01/2026policy_historyLatest

Policy History entry dated 05/01/2026 added a related policy link to Interspinous Fusion and Decompression Devices (for Kentucky Only).

05/01/2026coverage_rationale_revisionLatest

Coverage Rationale revised to update the list of unproven and not medically necessary indications: added vertebral joint implants that replace the disc and facet joints (e.g., MOTUS); broadened Dynamic Stabilization wording to 'for the treatment of spine pain'; clarified phrasing for Isolated Facet Joint Fusion and renamed Total Facet Arthroplasty to Facet Joint Replacement for treatment of spine pain.

Policy Summary

PayerUnitedHealthcare

PolicySpinal Fusion and Decompression (for Kentucky Only)

Policy CodePolicy CS365KY.05

Change TypeRevisions to coverage rationale, definitions, and applicable codes

Effective DateMay 1, 2026

Next Review Date

Key ActionMedical records must contain documentation that fully supports medical necessity, including relevant history, exam, and diagnostic test results; make records available upon request.

SourceLink

On This Page

Medical record documentation must fully support the medical necessity for the requested service. Records should include relevant medical history, physical examination findings, and results of pertinent diagnostic tests and procedures. Documentation must be legible, maintained in the patient’s medical record, and made available upon request. Submission of documentation does not guarantee coverage; benefit coverage is determined by applicable federal, state, and contractual requirements.

Billing Rule

Do not use removed CPT codes

The following CPT codes were removed from the applicable codes/supporting information per the policy revision history and must not be used when submitting claims or in supporting documentation for this policy.

63170
63172
63173
63185
63190
63191
63197
63200
63250
63251
63252
63265
These codes were removed from the policy's applicable codes/supporting information per the policy history; do not use them.

Documentation Required

Reference updated definitions and supporting information

Definitions for key procedures and terms were updated. Providers should reference and apply the current definitions when documenting clinical rationale for services submitted under this policy.

Updated definitions include: Dynamic Stabilization, Isolated Facet Joint Fusion, Staged Multiple Sessions, Total Facet Arthroplasty (Facet Joint Replacement), and Unremitting
When documenting clinical rationale, reference the policy’s current Description of Services, Clinical Evidence, and FDA information as applicable

Documentation Required

Reference updated codes in policy history

Policy revision history includes updates to codes and coding guidance. Review the policy history for details on code changes and effective dates before submitting claims.

Codes updated in the policy history include: 63251, 63252, 63265
Review the full policy and policy revision history for specific coverage, coding, and billing instructions when submitting claims