Cigna Healthcare (Commercial) · percutaneous image guided lumbar decompression

v1verified 2026-07-24manual-pull source

✗ investigational / not covered · commercial

Criteria checklist

0 of 5 ticked

Indications

enumerated: yes
covered:
investigational:
- percutaneous lumbar decompression (e.g., Vertos Medical MILD procedure) — experimental, investigational, or unproven (EIU)

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

Cigna (eviCore CMM-608 "Lumbar Decompression"; legacy mm_0139 content migrated here) deems percutaneous lumbar decompression (Vertos MILD) EIU. The determination is name-based / CPT-agnostic, so it persists across the 0275T -> 62330/62331 (2026) transition. More restrictive than Medicare (PILD covered only under CED, G0276). From the actual fetched eviCore PDF.

Ticks are a documentation aid — nothing is stored; they reset on reload.

Dot phrase

Cigna (eviCore CMM-608) deems percutaneous lumbar decompression (Vertos MILD) **EIU**.

.MILDCIGNA

This patient would be a candidate for percutaneous lumbar decompression, but MILD/PILD is not
a covered benefit under this plan: Cigna (eviCore CMM-608) deems the Vertos MILD procedure
experimental, investigational, and unproven. My clinical rationale is documented here: *** .
Alternatives have been discussed with the patient. Any appeal must contest the EIU position
itself.

Cautions

Medicare covers PILD only under Coverage with Evidence Development, billed G0276.
Regenerate if `cigna-commercial-mild.md` `version` advances.

Prior-auth pathway

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

Provenance

authority:
- type: commercial_policy
- id: Cigna eviCore CMM-608
- title: Lumbar Decompression
- delegated by: Cigna (authored by eviCore / Evernorth)
- applies because: Cigna delegates lumbar decompression UM to eviCore CMM-608 (legacy mm_0139 content migrated here)
source: https://www.evicore.com/sites/default/files/clinical-guidelines/2025-05/Cigna_CMM-608%20Lumb%20Decom_Final_V1.0.2025_Pub03.19.2025_upd05.29.2025.pdf
archived copy: sources/evicore_cmm608-lumbar-decomp_2025-07-01.pdf (sha256 6737048d6912… — kept in the content repo, not served here)
effective: 2025-07-01 · payor last reviewed: 2025-05-29 · we verified: 2026-07-24 · v1

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Change history

2026-07-24commercial cells: re-verify 27 source PDFs by SHA-256 (Carelon/eviCore/UHC/Cigna) - all unchanged vs committed archive; last_verified -> 2026-07-24 3615c231f0
2026-06-30Archive commercial source PDFs into sources/ + wire source_file/source_hash c5466694c8
2026-06-29Add commercial MILD/PILD cells (all investigational) + correct Medicare MILD CPT 4c790f8264