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Anthem Blue Cross Blue Shield / Elevance (Commercial) · percutaneous image guided lumbar decompression

v3verified 2026-07-24manual-pull source

✗ investigational / not covered · commercial

Criteria checklist

0 of 5 ticked
Indications
  • enumerated: yes
  • covered:
    • investigational:
      • percutaneous spinal surgical techniques (incl. MILD/PILD for lumbar spinal stenosis) — investigational and not medically necessary
    Conservative care
    • required: not stated in the policy
    • note: n/a — not covered
    Trial
    • required: no
    • min duration days: not stated in the policy
    • success criteria: not stated in the policy
    • threshold is binding: no
    Psychological evaluation
    • required: no
    • must clear: no
    • note posture: n/a
    Quantity limits
    • applies: no
    Payor-specific notes

    Anthem SURG.00071 deems percutaneous spinal surgery — explicitly including MILD/PILD for lumbar spinal stenosis — investigational/not medically necessary, with NO clinical-trial (CED) pathway. This is MORE restrictive than Medicare, which covers PILD under Coverage-with-Evidence-Development (NCD 150.13, billed G0276). CPT note: 0275T was deleted 2026-01-01 and replaced by Cat-I 62330/62331. Verified live 2026-07-24: the 2026-07-01 revision renamed the doc to "Percutaneous Spinal Surgery" and removed endoscopic/direct-visualization techniques from scope (62380 dropped) — MILD/PILD stays investigational. From the live Anthem policy page.

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    Dot phrase

    Anthem (SURG.00071, "Percutaneous Spinal Surgery", rev. 2026-07-01) deems percutaneous image-guided lumbar decompression, incl. MILD/PILD, **investigational** — no CED pathway.

    .MILDANTHEM
    This patient would be a candidate for percutaneous image-guided lumbar decompression, but
MILD/PILD is not a covered benefit under this plan: Anthem SURG.00071 ("Percutaneous Spinal
Surgery", rev. 2026-07-01) deems it investigational, and there is no CED pathway. My clinical
rationale is documented here: *** . Alternatives have been discussed with the patient. Any
appeal must contest the investigational determination itself.

    Cautions

    • Medicare covers PILD only under Coverage with Evidence Development, billed G0276.
    • CPT note: 0275T deleted 2026-01-01 -> 62330/62331 (62380 endoscopic now out of SURG.00071 scope). Regenerate if `anthem-commercial-mild.md` `version` advances.

    Prior-auth pathway

    • required: not stated in the policy
    • note: n/a — denied as investigational

    Provenance

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    Change history

    • 2026-07-24anthem/mild v3: live-page check caught SURG.00071 revision (eff 2026-07-01, renamed 'Percutaneous Spinal Surgery', endoscopic removed from scope -> 62380 dropped); MILD/PILD coverage position UNCHANGED (investigational, no CED); dot phrase resynced 6140f2847a
    • 2026-07-23mild/anthem v2: cpt gains 62330/62331 (2026 lumbar codes), drops off-scope 0274T d2b23bfceb
    • 2026-06-29Add commercial MILD/PILD cells (all investigational) + correct Medicare MILD CPT 4c790f8264