UnitedHealthcare Spine Procedures Coverage Update

Coverage Framework and Criteria

Coverage framework and references

Coverage and guidance are handled as follows for each spine topic:

Cervical Artificial Disc Replacement: If a Medicare LCD/LCA exists for the state/territory, compliance with that LCD/LCA is required; for states/territories without LCDs/LCAs, refer to the UnitedHealthcare Commercial Medical Policy titled Total Artificial Disc Replacement for the Spine.

Refer to applicable LCD/LCA table or UHC commercial policy as noted.

Cervical Spine Fusion Surgery: If a Medicare LCD/LCA exists for the state/territory, compliance with that LCD/LCA is required; otherwise refer to the UnitedHealthcare Commercial Medical Policy titled Spinal Fusion and Decompression.

Refer to applicable LCD/LCA table or UHC commercial policy as noted.

Cervical Non-Fusion Procedures: No Medicare LCDs/LCAs exist; refer to the UnitedHealthcare Commercial Medical Policy titled Spinal Fusion and Decompression for coverage guidance.

Follow UHC commercial policy guidance where no LCD/LCA applies.

Thoracic Spine Surgery: No Medicare NCD exists and LCDs/LCAs do not exist; refer to the UnitedHealthcare Commercial Medical Policy titled Spinal Fusion and Decompression for coverage guidance.

Use UHC commercial policy when no Medicare contractor guidance applies.

Scoliosis/Kyphosis Surgery: No Medicare NCD and no LCDs/LCAs exist; use InterQual Criteria (Procedures, Scoliosis or Kyphosis Surgery) as referenced for coverage criteria.

Refer to InterQual CP: Procedures when indicated.

Lumbar Spine Surgery: If a Medicare LCD/LCA exists for the state/territory, compliance with that LCD/LCA is required; for states/territories without LCDs/LCAs, refer to the UnitedHealthcare Commercial Medical Policy titled Spinal Fusion and Decompression.

Refer to applicable LCD/LCA table or UHC commercial policy as noted.

Interspinous and IPD devices: No Medicare NCDs exist and LCDs/LCAs do not exist; refer to the UnitedHealthcare Commercial Medical Policy titled Interspinous Fusion and Decompression Devices for coverage guidance.

Follow the referenced UHC commercial policy for device-specific criteria.

Minimally Invasive and Related Procedures: Where no LCD/LCA exists, refer to the UnitedHealthcare Commercial Medical Policy titled Minimally Invasive Spine Surgery Procedures (including percutaneous lumbar decompression and sacroplasty) for coverage guidance.

See UHC Minimally Invasive Spine Surgery Procedures policy for specific procedures.

Percutaneous Sacroiliac (SI) Joint Procedures: Medicare LCDs/LCAs exist for some states; where an LCD/LCA exists compliance is required; for states/territories without LCDs/LCAs, refer to the UnitedHealthcare Commercial Medical Policy titled Sacroiliac Joint Interventions.

Follow applicable Medicare contractor policy or UHC commercial policy as applicable.

Annular Closure Devices (ACDs): No Medicare NCDs or LCDs/LCAs exist; refer to the UnitedHealthcare Commercial Medical Policy titled Discogenic Pain Treatment for coverage guidance.

Use referenced UHC commercial policy for device-specific criteria.

Fusion and Bone Healing Products: No Medicare NCDs or LCDs/LCAs exist; refer to the UnitedHealthcare Commercial Medical Policy titled Spinal Fusion and Bone Healing Enhancement Products for coverage guidance.

Refer to UHC commercial policy for graft and bone healing product coverage.

The list of procedure and diagnosis codes shown in the Applicable Codes section is provided for reference only and is not exhaustive. Inclusion of a code in this policy does not, by itself, indicate that the service described is covered, that it meets medical necessity criteria, or that payment is guaranteed. Benefit coverage and any coverage limits are determined by the member's specific benefit plan and by applicable laws and other policies.

Listing a CPT, HCPCS, or ICD-10 code in this policy does not imply that the service represented by that code is covered or will be reimbursed. The code lists are intended to help providers identify services that may be relevant to the clinical topics addressed, but inclusion of a code is not a coverage determination and additional policies or benefit rules may apply.

Coverage for any service is ultimately governed by the member's specific benefit plan document. If the member's benefit plan conflicts with this policy, the member-specific benefit plan document supersedes this policy. For questions about a particular member's coverage, providers should refer to the benefit plan or contact the customer service number on the member ID card.

Applicable Codes (CPT/HCPCS/ICD-10)

Cervical Artificial Disc ReplacementCPT

22856	Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation; single interspace, cervical.
22858	Total disc arthroplasty (artificial disc), anterior approach; second level, cervical (List separately in addition to code for primary procedure).
22861	Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical.
22899	Unlisted procedure, spine.

Cervical Spine Fusion SurgeryCPT

22548	Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process.
22551	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2.
22554	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2.
22590	Arthrodesis, posterior technique, craniocervical (occiput-C2).
22595	Arthrodesis, posterior technique, atlas-axis (C1-C2).
22600	Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment.

Cervical Spine Surgery (Other Non-Fusion Procedures)CPT

22210

Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical.

Cervical artificial disc replacement and cervical fusion codesCPT

22856	Total disc arthroplasty, anterior approach; single interspace, cervical
22858	Total disc arthroplasty, anterior approach; second level, cervical
22861	Revision including replacement of total disc arthroplasty, anterior approach, single interspace; cervical
22899	Unlisted procedure, spine
22548	Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2
22551	Arthrodesis, anterior interbody, cervical below C2
22554	Arthrodesis, anterior interbody technique, cervical below C2
22590	Arthrodesis, posterior technique, craniocervical (occiput-C2)
22595	Arthrodesis, posterior technique, atlas-axis (C1-C2)
22600	Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2

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Cervical decompression and related spine procedure codesCPT

22830	Exploration of spinal fusion
22849	Reinsertion of spinal fixation device
22852	Removal of posterior segmental instrumentation
22854	Insertion of intervertebral biomechanical device(s) with integral anterior instrumentation
22855	Removal of anterior instrumentation
63001	Laminectomy with exploration and/or decompression, cervical, 2 vertebral segments
63015	Laminectomy with exploration and/or decompression, cervical, more than 2 segments
63020	Laminotomy (hemilaminectomy) with decompression of nerve root(s); cervical
63040	Laminotomy with decompression, reexploration, single interspace; cervical
63045	Laminectomy, facetectomy and foraminotomy, single cervical segment

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Thoracic spine surgery and deformity codesCPT

22206	Osteotomy of spine, posterior or posterolateral; thoracic
22212	Osteotomy of spine, posterior or posterolateral; thoracic
22222	Osteotomy of spine, anterior approach; thoracic
22532	Arthrodesis, lateral extracavitary technique; thoracic
22556	Arthrodesis, anterior interbody technique; thoracic
22610	Arthrodesis, posterior or posterolateral technique; thoracic

Spinal deformity arthrodesis codesCPT

22800	Arthrodesis, posterior; for spinal deformity, up to 6 vertebral segments
22802	Arthrodesis, posterior; 7 to 12 vertebral segments
22804	Arthrodesis, posterior; 13 or more vertebral segments
22808	Arthrodesis, anterior; for spinal deformity, 2 to 3 vertebral segments
22810	Arthrodesis, anterior; for spinal deformity, 4 to 7 vertebral segments
22812	Arthrodesis, anterior; for spinal deformity, 8 or more vertebral segments

Lumbar spine, interspinous devices, percutaneous procedures, sacroiliac fusion codesCPT/HCPCS

63005	Laminectomy with exploration and/or decompression, lumbar, 1 or 2 segments; except for spondylolisthesis
63012	Laminectomy with removal of abnormal facets and/or pars for spondylolisthesis, lumbar (Gill)
63017	Laminectomy with exploration and/or decompression, lumbar, more than 2 segments
63030	Foraminotomy and/or excision of herniated intervertebral disc; lumbar
63042	Laminotomy with decompression, reexploration, single interspace; lumbar
63056	Discectomy/herniated disc procedures, single segment; lumbar
63200	Laminectomy with release of tethered spinal cord, lumbar
22867	Insertion of interlaminar/interspinous stabilization/distraction device, without fusion, with open decompression, lumbar; single level
22868	Insertion of interlaminar/interspinous stabilization/distraction device, with open decompression, lumbar; second level
22869	Insertion of interlaminar/interspinous stabilization/distraction device, without open decompression or fusion, lumbar; single level

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Graft and unlisted procedure codesCPT

20930	Allograft, morselized, for spine surgery only
20931	Allograft code (listed in document)
20939	Bone marrow aspiration for bone grafting, spine surgery only
22899	Unlisted procedure, spine (used for several named contexts)

ICD-10 diagnosis codes related to sacral/sacroiliac and lumbosacral conditionsICD-10

M43.17	Spondylolisthesis, lumbosacral region
M43.18	Spondylolisthesis, sacral and sacrococcygeal region
M43.27	Fusion of spine, lumbosacral region
M43.28	Fusion of spine, sacral and sacrococcygeal region
M46.1	Sacroiliitis, not elsewhere classified
M51.17	Intervertebral disc disorders with radiculopathy, lumbosacral region
M53.2X7	Spinal instabilities, lumbosacral region
M53.2X8	Spinal instabilities, sacral and sacrococcygeal region
M53.3	Sacrococcygeal disorders, not elsewhere classified
M53.87	Other specified dorsopathies, lumbosacral region

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Referenced coding guidancemixed

No codes listed

None specified (coding)

Coding thresholds/requirementsNone specified in this policy for procedure or diagnosis code use; the Applicable Codes list is for reference only and does not itself indicate coverage or guarantee payment.

Benefit determinationCoverage is determined by the member-specific benefit plan document and applicable laws; inclusion of a code does not imply coverage.

Claims/payment implicationInclusion of a code does not imply any right to reimbursement or guarantee of claim payment; other policies and guidelines may apply.

Provider Responsibilities and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization requirements vary by procedure, member plan, and applicable LCD/LCA or UnitedHealthcare commercial policy. When prior authorization is required for services referenced in this policy, providers must obtain prior authorization from UnitedHealthcare or its delegated entity before rendering the service.

Follow applicable Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) where they exist.
For services governed by UnitedHealthcare commercial medical policies (for example, Interspinous Fusion and Decompression Devices; Minimally Invasive Spine Surgery Procedures; Sacroiliac Joint Interventions), follow the referenced commercial policy’s prior authorization rules.
If your facility’s utilization management is delegated, follow the delegate’s prior authorization processes and requirements.

Documentation Required

Documentation Requirements

Providers are expected to retain or have access to appropriate documentation to support medical necessity, coding, and claims for services rendered. Failure to retain or provide requested documentation may affect coverage determinations and claim payment.

Policy Background

This policy groups a range of spine procedures (including cervical artificial disc replacement, cervical and lumbar fusion and decompression, thoracic and deformity procedures, interspinous devices, percutaneous techniques such as sacroplasty, and sacroiliac joint interventions) and provides cross-references to applicable Medicare Local Coverage Determinations (LCDs/LCAs) and UnitedHealthcare commercial medical policies. Where an LCD/LCA exists for a specific state or territory, compliance with that LCD/LCA is required; where no LCD/LCA exists, the policy directs providers to the named UnitedHealthcare commercial policy or InterQual criteria for topic-specific clinical guidance and prior authorization requirements.

Definitions and Procedure Descriptions

Cervical Artificial Disc Replacement definition

DefinitionTotal disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation; single interspace, cervical (CPT 22856).

Additional levels/revisionSecond-level cervical total disc arthroplasty is CPT 22858 (list separately in addition to primary procedure); revision including replacement is CPT 22861.

Unlisted procedure codeUnlisted procedure, spine (CPT 22899) may be used when appropriate for cervical artificial disc procedures not otherwise described.

Interspinous process stabilization/distraction devices definition

DefinitionInsertion of interlaminar/interspinous stabilization/distraction device (with or without open decompression) in the lumbar spine; codes include CPT 22867–22870 describing single- and second-level insertion with or without decompression and image guidance when performed.