CurrentUnitedHealthcarePolicy CS031ID.B

Discogenic Pain Treatment (for Idaho Only)

This UnitedHealthcare medical policy (Idaho only, including Idaho Medicaid Plus) defines coverage rationale, not medically necessary determinations, and applicable procedure codes for annular closure devices, percutaneous injection of allogeneic cellular/tissue-based products, and thermal intradiscal procedures for treatment of discogenic pain. It includes clinical evidence summaries and references relevant CPT/HCPCS codes.

Policy Summary

PayerUnitedHealthcare

PolicyDiscogenic Pain Treatment (for Idaho Only)

Policy CodePolicy CS031ID.B

Change TypeCPT code addition; evidence and references updated; prior version archived

Effective DateJune 1, 2026

Next Review Date

Key ActionDocument patient selection criteria (skeletally mature with radiculopathy attributed to posterior/posterolateral herniation and annular defect 4-6 mm tall and 6-10 mm wide after primary discectomy at L4-S1) and ensure claims reflect added CPT code 63032 where appropriate.

POLICY UPDATE CHANGES

Added CPT code 63032 to Applicable Codes.

Updated Clinical Evidence and References sections to reflect the most current information.

Archived previous policy version CS031ID.A.

3Procedures designated not medically necessary

~15Referenced evidence studies/assessments summarized

1CPT code(s) added in this revision