CurrentUnitedHealthcarePolicy CSNCT0363.04

Interspinous Fusion and Decompression Devices (for North Carolina Only)

UnitedHealthcare medical policy applicable only to North Carolina governing interspinous fusion and decompression devices; refers medical necessity clinical criteria to the North Carolina Medicaid Clinical Coverage Policy Physician: 1A-30, Spinal Surgeries. Includes applicable procedure codes, documentation expectations, FDA informational note, and revision history.

Policy Summary

PayerUnitedHealthcare

PolicyInterspinous Fusion and Decompression Devices (for North Carolina Only)

Policy CodePolicy CSNCT0363.04

Change TypeRevisions (non-material); archived prior version

Effective DateJan 1, 2026

Next Review Date

Key ActionEnsure the medical record contains relevant history, physical exam, and diagnostic test results that fully support medical necessity and are legible and available upon request.

POLICY UPDATE CHANGES

Removed reference link to the Medical Policy titled Discogenic Pain Treatment (for North Carolina Only).

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required but does not guarantee coverage.

Archived previous policy version CSNCT0363.03

State-specificGeographic scope

8Procedure codes referenced

Coverage Summary

This UnitedHealthcare medical policy applies only to the state of North Carolina. For determination of medical necessity, refer to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Physician: 1A-30, Spinal Surgeries.

Medical Necessity Criteria

Coverage Rationale

For medical necessity clinical coverage criteria, refer to:

ALL of the following

Medical necessity clinical coverage criteria are determined by the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Physician: 1A-30, Spinal Surgeries.
Reference: NC Medicaid Clinical Coverage Policy Physician: 1A-30

Medical Records Documentation Used for Reviews

Coverage requires documentation supporting medical necessity:

Documentation may be required to assess whether the member meets the clinical criteria but does not guarantee coverage.

Patient's medical record must contain documentation that fully supports medical necessity for requested services.

Documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Documentation should be legible, maintained in the patient's medical record, and made available upon request.

Medical necessity: Determined by federal, state, or contractual requirements and applicable laws; documentation in the patient's medical record must fully support the requested services and may be required to assess whether the member meets clinical criteria but does not guarantee coverage.

Procedure Codes

Applicable procedure codes (reference only)CPT|mixed

22853	Insertion of interbody biomechanical device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g., screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure).
22854	Insertion of intervertebral biomechanical device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g., screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure).
22859	Insertion of intervertebral biomechanical device(s) (e.g., synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure).
22867	Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level.
22868	Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure).
22869	Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level.
22870	Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure).
22899	Unlisted procedure, spine.

State fee schedule exclusion notemixedNot Covered

22867/22868/22869/22870

Codes labeled with an asterisk (*) (22867, 22868, 22869, 22870) 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.

Documentation Required

Support medical necessity in chart

Ensure medical record contains relevant history, physical exam, and diagnostic test results that fully support medical necessity; records must be legible and available upon request.

Provider Actions & Operational Notes

Documentation Required

Reference state clinical criteria

When assessing medical necessity, reference the North Carolina Medicaid Clinical Coverage Policy Physician: 1A-30, Spinal Surgeries to determine coverage criteria.

Billing Rule

State fee schedule exclusion

Codes noted below 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.

Affected codes: 22867, 22868, 22869, 22870

Revision History

revisedLatest