Prior authorization governed by Univera policy

Prior authorization for intradiscal procedures is governed by Univera Healthcare medical policy determinations; intradiscal procedures listed as investigational are not supported as medically necessary and are subject to PA requirements per the payer.

• Submit clinical rationale and device details when requesting PA

PA implied for device‑specific intradiscal techniques

Prior authorization is implied for intradiscal procedures given the variety of device‑specific techniques and their investigational status; providers should submit clinical rationale and device/technique details with PA requests.

• Include procedure type, device model (e.g., Dekompressor, Nucleotome, SpineJet) and intended mechanism in PA submissions

PA may be required for E/I‑coded intradiscal procedures

Procedures represented by the listed CPT and HCPCS codes are designated Experimental/Investigational (E/I) and may require prior authorization or be subject to coverage determination.

• Codes include CPT 22526, 22527, 62287, 62330, 62331, 0274T/0275T (term), 0627T–0630T and HCPCS C2614, G0276, S2348

HCPCS codes C2614, G0276, S2348 tied to PA/coverage

HCPCS codes C2614, G0276, and S2348 are listed as Experimental/Investigational in this policy; PA requirements depend on payer/product benefit and code coverage.

• C2614 = Probe, percutaneous lumbar discectomy (E/I)
• G0276 = PILD or placebo-control in approved CED trial (E/I)
• S2348 = Percutaneous decompression using RF energy (E/I)

Document conservative management and surgical referral rationale

Document prior conservative care and the rationale for choosing an intradiscal intervention, including why standard surgical discectomy or other conventional pathways are not appropriate for this patient.

• Record prior nonoperative treatments and objective reasons for referral to intradiscal procedure
• If applicable, document why standard surgical discectomy was not selected or is contraindicated

Document failure of conservative therapy prior to intervention

Evidence summaries indicate that patients enrolled in key trials generally had failed conservative therapy; providers should document failure of conservative management before intradiscal interventions when applicable.

• Document specific conservative therapies tried and duration (e.g., ESIs, physical therapy)

Basis for medical necessity documentation

Medical necessity determinations are based on evidence‑based literature, national guidelines, federal/state law, and the member's subscriber contract; include citations or guideline references in PA/documentation when relevant.

• Reference applicable guideline or evidence when submitting PA or appeals

Required procedure documentation elements

Documentation for intradiscal procedures must include the procedure type, targeted disc level(s), device used (when applicable), and the image guidance method (fluoroscopy or endoscopic visualization).

• Specify single vs. multilevel (and list additional level codes if applicable)
• Indicate image guidance method used (fluoroscopy, CT, or endoscopic visualization)

Include device regulatory status in documentation

FDA 510(k) clearance or regulatory status for specific intradiscal devices is noted in the policy and may be relevant to documentation of device use (e.g., Dekompressor, Nucleotome, SpineJet, Baylis devices); include device regulatory information when available.

• List device name and FDA status in the clinical record or PA submission

Check product‑specific applicability and contract coverage

Coverage and PA requirements may vary by product: if a Medicare/Medicaid product covers the service, medical policy criteria apply unless there is a national/local Medicare or NY Medicaid guideline; if a product does not cover the service, policy criteria do not apply.

• Check member’s product benefit and local Medicare/Medicaid guidance before submitting PA

Denial risk for investigational intradiscal procedures

Claims for intradiscal procedures listed as investigational are subject to denial as investigational/not medically necessary; submitting required documentation does not guarantee coverage.

• Denials may result when procedures are designated investigational in the policy

Non‑coverage risk for procedures with limited/conflicting evidence (e.g., APD)

Procedures with limited or conflicting evidence (for example APD) have been associated with poorer or inconsistent outcomes and may be judged investigational or not medically necessary, increasing risk of non‑coverage.

• APD trials and systematic reviews reported inferior or conflicting outcomes compared with standard discectomy

Coverage risk associated with E/I or NMN procedure codes

Codes designated E/I or NMN in this policy may not be covered and use of those CPT/HCPCS codes could trigger denials or additional review; providers should verify code coverage and obtain PA when indicated.

• Examples include CPT codes 22526, 62287, 62330/62331, 0627T–0630T and HCPCS C2614, G0276, S2348

Verify contract/product coverage before performing procedure

Services are contract dependent; if a product does not cover a service, medical policy criteria do not apply — confirm member benefit and coverage prior to scheduling procedures.

• Verify commercial/Medicaid/Medicare product coverage and apply local guidance (eMedNY or national/local Medicare) as required

Imaging requirements not specified in excerpt

The policy bases coverage on clinical evidence and guidelines; specific imaging requirements are not provided in this excerpt.

Fluoroscopy or endoscopic visualization required for APD, endoscopic discectomy, IDET/IDTA

For APD, endoscopic discectomy, and intradiscal electrothermal annuloplasty (IDET/IDTA), procedures are performed under fluoroscopic guidance or with endoscopic visualization and documentation should reflect the image guidance used.

• Document fluoroscopy or endoscopic visualization used during the procedure.

Fluoroscopy or CT image guidance for percutaneous decompression and injections

CPT descriptions for percutaneous decompression, intradiscal injections, and percutaneous laminotomy/laminectomy reference fluoroscopic or CT image guidance; document the type of image guidance used when applicable.

• Specify fluoroscopy or CT guidance in operative and billing records when using codes that reference imaging guidance.

PILD (G0276) is image‑guided—document image guidance

The HCPCS code G0276 references percutaneous image‑guided lumbar decompression (PILD), indicating the procedure is image‑guided; document image guidance when billing this service.

• When billing G0276, indicate the image‑guided PILD technique and any trial/CED context if applicable.