ModifiedUnitedHealthcarePolicy CS365OH.D

Spinal Fusion and Decompression (for Ohio Only)

Clinical policy governing medical necessity and coverage of spinal fusion and decompression procedures for UnitedHealthcare members in Ohio; includes proven indications, unproven procedures, and references to InterQual criteria for specific procedure types.

Policy Summary

PayerUnitedHealthcare

PolicySpinal Fusion and Decompression (for Ohio Only)

Policy CodePolicy CS365OH.D

Change TypeRevised unproven procedure listremoved CPT codes

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionDocument medical necessity using InterQual CP criteria and include complete medical record documentation when requesting authorization.

SourceLink

POLICY UPDATE CHANGES

Revised list of unproven and not medically necessary indications.

Added 'vertebral joint implants that replace the disc and facet joints (e.g., MOTUS) for the treatment of spine pain'.

Replaced specific indications wording to broaden 'Dynamic Stabilization systems' to 'for the treatment of spine pain'.

Removed several CPT codes (63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, and 63265) from Applicable Codes.

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services.

InterQualexternal clinical criteria

Ohiostate

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

4unproven procedures listed

1documentation requirement

Coverage and Medical Necessity Criteria

Medically necessary when InterQual criteria met

Covered when InterQual CP criteria are met for the specific procedure type.

InterQual-based coverage: Coverage for decompression and/or fusion procedures requires meeting the InterQual CP: Procedures criteria corresponding to the specific surgery (e.g., 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)).

Refer to InterQual for specific clinical entry and continuation criteria.

Unproven / Not medically necessary procedures

Not medically necessary (unproven) — none of the following are covered.

Unproven procedures: 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).

These procedures are considered unproven due to insufficient evidence of efficacy.

Staged Multiple Sessions considered unproven

Staged sessions.

Staged Multiple Sessions: Dividing treatment of symptomatic, multisite spinal pathology into staged multiple sessions when one session can address all sites is unproven and not medically necessary.

Staged Multiple Sessions includes procedures performed on different days or requiring an additional anesthesia session.

Multiple Serial/Staged Spine Procedures — Evidence-based stance

Not supported when ALL of the following are true.

Multiple serial/staged decompression: Dividing spine decompression procedures into serial, multiple, or staged sessions when a single session can address all sites.

There is insufficient evidence of efficacy to support this practice.

Motion-preserving systems and facet/vertebral joint replacements — Evidence summary

Coverage stance for motion-preserving and replacement devices (summary of evidence and limitations).

Dynamic stabilization (e.g., Dynesys): Current evidence is insufficient from well-designed, long-term randomized controlled trials to conclude a significant advantage over conventional fusion; most studies are retrospective or case series, and complication and reoperation rates relative to fusion are uncertain (Pham et al. 2016 reported pooled complications and ~11.3% reoperation among studies reporting revisions).

Evidence limited by study design and follow-up duration.

Facet joint replacement/arthroplasty (e.g., TOPS): Randomized and interim trial data show promising short-term outcomes (e.g., higher composite clinical success at 24 months in some RCT data), but evidence is limited by short follow-up, potential bias, and low evidence grade; longer-term data are needed to assess durability and safety.

Nassr et al. 2024 RCT showed superior composite clinical success at 24 months; ECRI rated evidence low.

Isolated facet joint fusion: No studies evaluate isolated facet joint fusion performed alone without concomitant decompression; evidence is insufficient to determine safety or effectiveness.

The policy considers procedures that divide treatment of symptomatic, multisite spinal pathology into separate operative sessions when a single session can address all sites to be unproven and not medically necessary. This includes anterior or posterior approaches performed in serial or as Staged Multiple Sessions when evidence of safety and efficacy is insufficient to support staging rather than addressing all operative targets in a single session.

The document states that there are no studies identified that evaluate Isolated Facet Joint Fusion when performed alone (that is, without an accompanying decompression). Because clinical evidence is lacking, isolated facet joint fusion is explicitly not supported by the evidence and is included in the policy's unproven/not medically necessary list.

The policy's revised list of unproven and not medically necessary indications now explicitly includes vertebral joint implants that replace the disc and facet joints (e.g., MOTUS). The list also names Dynamic Stabilization systems, Facet Joint Replacement, and Isolated Facet Joint Fusion (with or without instrumentation) as procedures considered unproven due to insufficient evidence of efficacy.

Several definitions previously used in the policy were removed in the revision notes. The removed terms include Disabling Symptoms, Lumbar Spinal Stenosis (LSS), Progressive, Radicular Pain, and Spinal Fusion. These removals are recorded in the Policy History and Summary of Changes.

The removal of definitions for terms such as Disabling Symptoms and Lumbar Spinal Stenosis (LSS) suggests that any prior coverage criteria that explicitly relied on those defined terms may no longer apply as written. The policy history notes these definition removals but does not include replacement coverage language within the extracted history entries.

Policy history entries explicitly document that definitions including Disabling Symptoms and Lumbar Spinal Stenosis (LSS) were removed. These revision notes are recorded in the Policy History / Summary of Changes and may affect interpretation of earlier, definition-dependent criteria.

Within the provided policy history chunks there are no new explicit coverage exclusions added beyond the listed unproven/not medically necessary procedures; several history entries are administrative or note updates to document sections but do not set out separate, explicit exclusion statements in these excerpts.

The Policy History indicates that multiple CPT codes were removed from the Applicable Codes list. The removed codes include (but may not be limited to) 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, and 63265. These codes should no longer be used for coverage determinations under this policy section as recorded in the Summary of Changes.

Several Policy History entries in this extract are administrative in nature and do not contain new coverage criteria, exclusions, or medical necessity determinations. These entries document archival of prior policy versions and updates to document sections (Description of Services, Clinical Evidence, FDA, References) without adding substantive new coverage rules in the quoted chunks.

These policy history chunks do not include explicit coverage criteria, exclusions, or statements that label additional procedures as not medically necessary. The excerpts largely reflect revision notes and administrative history rather than new substantive coverage language.

The policy lists several motion-preserving technologies and related procedures as unproven and not medically necessary, including Dynamic Stabilization systems, Facet Joint Replacement, Isolated Facet Joint Fusion, and vertebral joint implants that replace the disc and facet joints. The evidence summaries cited elsewhere in the policy note limited, mostly nonrandomized or short-term data for these device types.

The policy specifically notes that dividing decompression into multiple or staged procedures when a single session can address all sites is unsupported by evidence. Such multiple serial/staged decompression approaches are considered unproven and may be regarded as not medically necessary.

The Summary of Changes broadened and revised the list of device and procedure types considered unproven or not medically necessary. Newly added items and broadened wording extend the list to include additional vertebral joint replacement devices and expand the stated indications for dynamic stabilization and facet replacement to 'for the treatment of spine pain.'

In this section of the policy history extract there are no explicit statements newly designating additional services as not medically necessary; several history lines are administrative summaries or refer back to previously stated unproven items.

Applicable Procedure and Device Codes

Applicable procedure codes (selected block)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 (e.g., pedicle/vertebral body subtraction); thoracic.
22207	Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (e.g., pedicle/vertebral body subtraction); lumbar.

Applicable procedure codes (additional blocks)CPT

22208	Osteotomy of spine, posterior or posterolateral approach, 3 columns, each additional vertebral segment (List separately in addition to code for primary procedure).
22210	Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical.
22532	Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic.
22533	Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar.
22551	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2.
22612	Arthrodesis, posterior or posterolateral technique, single interspace; lumbar.
22800	Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments.
22899	Unlisted procedure, spine.
62380	Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar.
63001	Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, 1 or 2 vertebral segments; cervical.

1–10 of 11

1/2

Applicable CPT Codes (selected: laminectomy/facetectomy/foraminotomy)CPT

63045	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s]), single vertebral segment; cervical.
63046	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s]), single vertebral segment; thoracic.
63047	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s]), single vertebral segment; lumbar.
63048	Each additional vertebral segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure).

Applicable CPT Codes (corpectomy, laminectomy, discectomy, neoplasm excision)CPT

63050	Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments.
63051	Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements.
63052	Laminectomy, facetectomy, or foraminotomy during posterior interbody arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure).
63053	Each additional vertebral segment during posterior interbody arthrodesis, lumbar (List separately in addition to code for primary procedure).
63055	Transpedicular approach with decompression, single segment; thoracic.
63056	Transpedicular approach with decompression, single segment; lumbar.
63057	Each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure).
63064	Costovertebral approach with decompression (thoracic).
63066	Costovertebral approach with decompression, each additional segment (List separately in addition to code for primary).
63075	Discectomy, anterior, with decompression; cervical, single interspace.

1–10 of 46

1/5

Removed CPT CodesCPT

63170	removed
63172	removed
63173	removed
63185	removed
63190	removed
63191	removed
63197	removed
63200	removed
63250	removed
63251	removed

1–10 of 12

1/2

FDA Device Approvals Mentionedmixed

PMA P220002

TOPS System premarket approval identifier

Applicable CPT Codes RemovedCPTNot Covered

63170	CPT code removed (as listed in policy history)
63172	CPT code removed (as listed in policy history)
63173	CPT code removed (as listed in policy history)
63185	CPT code removed (as listed in policy history)
63190	CPT code removed (as listed in policy history)
63191	CPT code removed (as listed in policy history)
63197	CPT code removed (as listed in policy history)
63200	CPT code removed (as listed in policy history)
63250	CPT code removed (as listed in policy history)

Removed CPT CodesCPTNot Covered

63170
63172
63173
63185
63190
63191
63197
63200
63250
63251

1–10 of 12

1/2

Follow-up duration reported in studies

Typical follow-up rangeMost studies report follow-up typically 12–36 months (examples: mean 33.7 months for Dynesys series; 24 months primary outcome in Nassr RCT; 12 months for MOTUS TJR)

Dynesys (Pham et al. 2016)Mean follow-up 33.7 months in pooled series of 1,166 individuals; reported surgical site infection, screw loosening and reoperation rates

Facet arthroplasty RCT (Nassr et al. 2024)Primary outcome analysis included participants with up to 24 months postoperative follow-up

MOTUS TJR (Nunley et al. 2025)Reported outcomes at 12 months with noted limitation of short-term follow-up

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization / Medical Necessity

Prior authorization/medical necessity: No specific prior authorization requirements are listed in this section. Medical necessity for covered spinal procedures is evaluated using InterQual® CP criteria for the listed decompression and fusion procedures. Presence of medical records documentation does not guarantee coverage.

InterQual® CP: Decompression +/- Fusion (Cervical, Lumbar, Thoracic)
InterQual® CP: Fusion (Cervical, Lumbar, Thoracic)
InterQual® CP: Scoliosis or Kyphosis Surgery (including Pediatric)

Documentation Required

Documentation and Coverage Determination

Medical records documentation may be required to assess whether the member meets clinical criteria. Benefit coverage is determined by federal, state, or contractual requirements; those laws and contracts govern coverage determinations.

Background and Scope

Background: Spinal fusion and decompression procedures are established treatments for selected causes of spine pain. The policy relies on external clinical entry criteria (InterQual) for evaluation of medical necessity for specific decompression and fusion procedures, and recognizes that certain novel motion-preserving or joint-replacement approaches lack sufficient evidence to be considered proven alternatives.

Definitions and Term Updates

Dynamic Stabilization

DefinitionA surgical procedure that stabilizes the spine with the insertion of a motion-preserving, flexible implant (rods, cords, spacers) designed to provide more mobility than traditional fusion.

Also calledFlexible fusion or soft stabilization.

Policy statusListed as unproven / not medically necessary for the treatment of spine pain in this policy revision.

Facet Joint Replacement

DefinitionTotal facet arthroplasty that replaces the facet joints using flexible materials as an alternative to fusion.

Device example and evidenceTOPS System (posterior pedicle screw–based implant) has RCT and case-series data; ECRI rated evidence low and policy notes insufficient long-term RCT data.

Policy Revision History

2026-05-01revisionLatest

Revised Coverage Rationale: updated list of unproven and not medically necessary indications (broadened Dynamic Stabilization and other entries; added vertebral joint implants and facet joint replacement language).

2026-05-01definitions_updated

Added definition for 'Facet Joint Replacement' and removed multiple prior definitions (Disabling Symptoms; Lumbar Spinal Stenosis (LSS); Progressive; Radicular Pain; Spinal Fusion; Spondylolisthesis; Spondylolysis; Total Facet Arthroplasty; Unremitting).

2026-05-01

Policy Summary

PayerUnitedHealthcare

PolicySpinal Fusion and Decompression (for Ohio Only)

Policy CodePolicy CS365OH.D

Change TypeRevised unproven procedure listremoved CPT codes

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionDocument medical necessity using InterQual CP criteria and include complete medical record documentation when requesting authorization.

SourceLink

On This Page

No identified clinical studies of facet fusion alone.

Vertebral total joint replacement (MOTUS TJR): Comparative nonrandomized data demonstrate improvements versus fusion at 12 months, but limitations include lack of randomization and short-term follow-up; further long-term randomized or comparative studies are required.

Nunley et al. 2025 reported 12-month outcomes with MOTUS; longer follow-up needed.

Documentation may be requested to substantiate coverage under Ohio Administrative Code 5160-101 when applicable
Coverage determinations follow federal, state, and contractual requirements

Documentation Required

Documentation Required for Authorization

The patient's medical record must fully support the medical necessity for the requested services. Required documentation includes relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation must be legible, maintained in the patient record, and made available upon request.

History: relevant clinical history and prior conservative treatments
Exam: focused physical examination findings supporting the indication
Diagnostics: imaging reports (e.g., MRI, CT), electrodiagnostic testing when applicable, and other pertinent test results
Availability: medical record must be legible and available upon request

Denial Risk

Denial Risk for Unproven Procedures and Staged Sessions

Requests for procedures determined to be unproven (for example, Dynamic Stabilization systems, Facet Joint Replacement, Isolated Facet Joint Fusion, vertebral joint implants that replace the disc and facet joints) may be denied as not medically necessary. Dividing decompression into multiple serial or staged sessions when one session could address all sites is considered unproven and not medically necessary.

Unproven / Not Medically Necessary: 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/Staged Procedures: Serial/staged decompression procedures when a single session could address all sites

Note

Device Information / FDA Databases

Device information is provided for informational purposes only. Providers may look up device regulatory and clearance status in FDA databases using the product name.

FDA device databases: PMN (510(k)) and PMA searchable pages (accessdata.fda.gov) — search by product name
Information accessed October 30, 2025 (as referenced in source)

Billing Rule

CPT Coding and Removed Codes — Potential Claim Impact

Billing and coding: use the applicable CPT descriptions for the spine procedures when submitting claims. Note that the policy revision removed a list of CPT codes; claims using removed codes may be impacted and providers should verify current applicable codes and prior authorization rules before claim submission.

Use current CPT code descriptions for decompression, fusion, corpectomy, laminectomy, discectomy, laminoplasty, and related procedures
Removed CPT codes (examples listed in revision history): 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265 — verify current code lists before submitting claims
Claims submitted with codes removed from the policy may be denied or require alternate coding

Note

Policy History and Administrative Notes

Policy history in this section is administrative and documents revisions to definitions, supporting information (Description of Services, Clinical Evidence, FDA, References), and archived previous policy versions. These history entries do not themselves create specific provider action requirements; however, providers should reference the current policy for operative definitions and documentation expectations.

Revision notes: updated definitions (e.g., Dynamic Stabilization, Isolated Facet Joint Fusion), removed several definitions, and updated supporting sections
Archived prior policy version: CS365OH.C
Policy history entries do not list additional prior authorization criteria beyond those already stated

Documentation Required

No Explicit Authorization/Denial Triggers in History — Provider Action

Operational reminders: absence of explicit prior authorization or denial triggers in the historical entries means providers must rely on the clinical criteria and documentation requirements in the current policy and any payer-specific prior authorization portal or guidance.

If payer prior authorization is required elsewhere, follow payer portals/processes — this policy section does not specify additional prior authorization steps
Insufficient documentation of medical necessity (history, exam, diagnostic results) may lead to denial

Policy statusFacet Joint Replacement is listed as unproven / not medically necessary for treatment of spine pain in this revision.

Isolated Facet Joint Fusion

DefinitionFacet joint fusion performed without decompression, typically using allograft bone dowels made from donated cortical bone.

EvidenceNo studies were identified evaluating isolated facet joint fusion performed alone without concomitant decompression.

Policy statusConsidered unproven / not medically necessary per the policy (no evidence to support safety or effectiveness).

Staged Multiple Sessions

DefinitionProcedures performed on different days or those requiring an additional anesthesia session (i.e., dividing treatment into separate operative sessions).

Policy rationaleDividing treatment of symptomatic, multisite spinal pathology into staged multiple sessions when one session can address all sites is unproven and not medically necessary.

Denial riskRequests for staged multiple sessions may be denied as unsupported by evidence when a single session could address all sites.

Back pain / surgical indication

Clinical indicationBack pain from mechanical or structural spine problems or nerve compression; surgery considered when conservative treatments fail.

Treatment contextSpinal fusion and decompression are established options for certain causes of spine pain; motion-preserving procedures are alternatives under study.

Policy applicationSurgery is considered when conservative measures do not control pain; InterQual criteria referenced for determining medical necessity of specific procedures.

Motion-preserving systems

ScopeTechnologies intended to preserve spinal motion, e.g., dynamic stabilization systems, facet joint replacement, and total joint replacement approaches.

Evidence summaryCurrent evidence is limited (mostly nonrandomized cohorts or short-term RCT data); long-term comparative effectiveness and safety remain uncertain.

Policy stanceMotion-preserving systems are considered unproven / not medically necessary pending higher-quality long-term evidence.

Facet Joint Replacement (new term)

Term addedFacet Joint Replacement — definition added to the policy (new defined term).

Definition textFull text of the newly added definition is recorded elsewhere in the document (definition content present in Definitions section).

Policy contextAdded to the list of unproven/not medically necessary procedures in the revision summary.

Policy terms referenced/removed

Terms removed or referencedSeveral clinical terms were referenced in Summary of Changes and/or removed (examples include Disabling Symptoms; Lumbar Spinal Stenosis; Progressive; Radicular Pain).

Scope of changesDefinitions for multiple terms were removed or updated across the policy history entries.

Documentation noteProviders should reference the current policy version because removed/modified terms may affect prior criteria wording.

Facet Joint Replacement (definition added)

Definition addedFacet Joint Replacement — definition added (policy notes addition, full text included in Definitions section).

Evidence contextAdded term aligns with revisions to unproven/not medically necessary device list.

Action for providersTreat facet joint replacement requests as subject to the updated policy definitions and evidence review.

Disabling Symptoms

Term removedDisabling Symptoms — definition removed from the policy in this revision.

ImplicationRemoval may affect prior coverage language that referenced this term; providers should consult current criteria.

DocumentationPolicy history documents the removal but does not provide replacement wording in the extracted segments.

Lumbar Spinal Stenosis (LSS)

Term removedLumbar Spinal Stenosis (LSS) — definition removed from the policy.

ImplicationProviders should verify current criteria where LSS was previously used to determine indications, as removal may change interpretation.

Location in historyDocumented in the Policy History / Summary of Changes entries.

Disabling Symptoms (removed)

Term removedDisabling Symptoms — noted as removed from policy definitions in revision history.

Potential effectMay affect prior criteria that referenced 'Disabling Symptoms'; consult current policy for authoritative criteria.

ReferenceListed in Policy History / Summary of Changes entries.

Lumbar Spinal Stenosis (LSS) (removed)

Term removedLumbar Spinal Stenosis (LSS) — removed from definitions per policy history.

Note to cliniciansRemoval is recorded in revision notes; verify clinical criteria location and wording in current policy for LSS-related indications.

Policy history locationAppears in multiple Policy History chunks summarizing removed definitions.

Unremitting (updated)

Term updatedUnremitting — updated definition referenced in Summary of Changes entries.

LocationNoted in Policy History / Revision Information; consult current policy text for exact wording.

Provider actionUse the updated definition recorded in the current policy when documenting indications described as 'unremitting'.

Dynamic Stabilization (updated)

Definition updatedDynamic Stabilization — updated definition recorded in policy history; see Definitions section for current wording (motion-preserving flexible implant).

Also calledFlexible fusion or soft stabilization.

Policy statusListed among unproven/not medically necessary procedures for treatment of spine pain in the revision summary.

Isolated Facet Joint Fusion (updated)

Definition updatedIsolated Facet Joint Fusion — definition updated as noted in policy history; defined as facet joint fusion without decompression using allograft bone dowels.

Evidence noteNo studies evaluate isolated facet joint fusion performed alone; policy lists it as unproven/not medically necessary.

Documentation guidanceProviders should reference the updated definition when documenting indication and procedure rationale.

Removed multiple CPT codes from the Applicable Codes list (63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265).

2026-05-01documentation_clarification

Added language clarifying that benefit coverage is determined by federal/state/contractual requirements and that medical records may be required to assess clinical criteria but do not guarantee coverage; specified required documentation elements (history, exam, diagnostic test results).

2026-05-01supporting_info_update

Updated Description of Services, Clinical Evidence, FDA, and References to reflect current information and archived prior policy version CS365OH.C.