Spinal Fusion and Decompression (for Nebraska Only)
Nebraska-only UnitedHealthcare medical policy describing coverage rationale, referenced InterQual criteria for decompression and fusion procedures by region (cervical, thoracic, lumbar), items considered unproven/not medically necessary (e.g., dynamic stabilization, facet joint replacement, isolated facet joint fusion, vertebral joint implants), applicable CPT/T proprietary codes, documentation requirements, definitions, FDA/device notes, and references. This is Part 1 of 5.
Revised list of unproven and not medically necessary indications: added 'vertebral joint implants that replace the disc and facet joints (e.g., MOTUS)' and updated wording for dynamic stabilization, isolated facet joint fusion, and facet joint arthroplasty to apply to treatment of spine pain.
Replaced/clarified specific wording for several unproven items; removed a reference link in Medical Records Documentation section and added language clarifying documentation requirement.
Added reference link to the Medical Policy titled Interspinous Fusion and Decompression Devices (for Nebraska Only).
Added language that the patient's medical record must contain documentation that fully supports medical necessity for requested services.
Added definition of 'Facet Joint Replacement'.
Removed CPT codes 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, and 63265.
Updated supporting information: Description of Services, Clinical Evidence, FDA, and References; archived previous policy version CS365NE.D.
Noted applicability or changes regarding 'Staged Multiple Sessions' and 'Isolated Facet Joint Fusion' across revision history entries.