G0276, Blinded procedure for lumbar stenosis, percutaneous image-guided lumbar
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage, but it does not guarantee coverage; reference member plan documents and guidelines.
- No explicit documentation requirements (e.g., required medical records, test results, or specific clinical notes) are specified in this policy.
- From Instructions for Use: "When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs. Before using this policy, please check the member specific benefit plan document and any applicable federal or state mandates."
- From Instructions for Use: "This Medical Policy may also be applied to Medicare Advantage plans in certain instances. In the absence of a Medicare National Coverage Determination (NCD), Local Coverage Determination (LCD), or other Medicare coverage guidance, CMS allows a Medicare Advantage Organization (MAO) to create its own coverage determinations, using objective evidence-based rationale relying on authoritative evidence (Medicare IOM Pub. No. 100-16, Ch. 4, §90.5)."
- From Instructions for Use: "UnitedHealthcare may also use tools developed by third parties, such as the InterQual ® criteria, to assist us in administering health benefits."
- For repeat procedures beyond specified intervals (e.g., beyond 12 months), submission of clinical review documentation justifying continued treatment.
Key Coverage Criteria
- Cover Routine Patient Costs for a Qualifying Individual participating in an Approved Clinical Trial as required by PPACA for plan years starting on/after 2014; benefits include reasonable and necessary items/services to prevent, diagnose, and treat complications arising from participation.
- No explicit "Covered Indications" or "Medically Necessary" indications are provided in this policy document.
- Coverage decisions are to be determined by the member specific benefit plan document (see Instructions for Use).
- Epiduroscopy / epidural lysis of adhesions: proposed for diagnosis/treatment of intractable LBP (including failed back surgery syndrome) by visualizing and lysing adhesions and injecting medications (insufficient high-quality evidence to support routine clinical use).
- Kyphoplasty (balloon-assisted vertebroplasty): restore bone height for painful osteoporotic compression fractures (OVCFs); NICE and other assessments note kyphoplasty may be a reasonable alternative to vertebroplasty for recent fractures.
- Sacropasty: injection of PMMA into sacrum for sacral insufficiency fractures (SIFs) in osteoporotic patients to stabilize fracture and relieve pain (developing indication).
17 Active Policies
UHC-POL-clinical-trials, Clinical Trials
UHC-POL-minimally-invasive-spine-surgery, Minimally Invasive Spine Surgery Procedures
AETNA-CPB-0016, Back Pain - Invasive Procedures
ADM1001.027, Clinical Trial Treatment or Therapy
SUR712.035, Image-Guided Minimally Invasive Decompression for Spinal Stenosis
BCBSIL-ADM1001.027, Clinical Trial Treatment or Therapy
BCBSIL-SUR712.035, Image-Guided Minimally Invasive Decompression for Spinal Stenosis
BCBSMT-ADM1001.027, Clinical Trial Treatment or Therapy
BCBSMT-SUR712.035, Image-Guided Minimally Invasive Decompression for Spinal Stenosis
BCBSNM-ADM1001.027, Clinical Trial Treatment or Therapy
BCBSNM-SUR712.035, Image-Guided Minimally Invasive Decompression for Spinal Stenosis
BCBSOK-ADM1001.027, Clinical Trial Treatment or Therapy
BCBSOK-SUR712.035, Image-Guided Minimally Invasive Decompression for Spinal Stenosis
UMR-POL-UMR-clinical-trials, Clinical Trials
UMR-POL-UMR-minimally-invasive-spine-surgery, Minimally Invasive Spine Surgery Procedures
SUREST-POL-SUREST-clinical-trials, Clinical Trials
SUREST-POL-SUREST-minimally-invasive-spine-surgery, Minimally Invasive Spine Surgery Procedures
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.