MINIMALLY INVASIVE SPINE PROCEDURES · GUIDE 01 OF 04
MILD® Procedure
Minimally Invasive Lumbar Decompression Also reported as Percutaneous Image-Guided Lumbar Decompression (PILD)
A comprehensive operational reference on clinical appropriateness, medical necessity, Medicare and commercial payer coverage, prior authorization workflow, coding fundamentals, and denial prevention for the minimally invasive decompression of lumbar spinal stenosis caused by hypertrophied ligamentum flavum.
MSK Specialty Procedure Library™Clinical Procedure Guide Standard v1.0GoHealthcare Practice Solutions
1. Evidence at a Glance
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This one-page executive summary orients prior authorization, utilization management, revenue cycle, and clinical teams before the detailed sections that follow. Every entry is expanded and sourced later in this guide.
Domain Summary
Procedure Percutaneous, image-guided debulking of hypertrophied ligamentum flavum (and small
lamina portions) to decompress the central lumbar canal. No implant is placed.
Medicare NCD NCD 150.13 — PILD is covered only under Coverage with Evidence Development
(CED); the beneficiary must be enrolled in a CMS-approved prospective longitudinal study using an FDA-cleared device.
Medicare LCD/LCA No separate national LCD supersedes the NCD; MAC articles operationalize CED claim edits.
Outside CED, traditional Medicare does not cover the service.
Commercial Fragmented. Many national plans classify image-guided MILD as experimental / coverage investigational for lumbar spinal stenosis; a minority cover under narrow criteria. Always
verify the member-specific policy.
Evidence level Society guidance is favorable for well-selected patients (ASPN 2022 Grade A; MIST 2.0),
while several payer evidence reviews rate the comparative evidence as low quality — the source of the coverage split.
Image guidance Required. Fluoroscopy or CT. Pre-procedure MRI or CT-myelogram must document central
canal stenosis with ligamentum flavum hypertrophy (LFH).
Prior authorization Effectively mandatory for commercial plans; frequently delegated to eviCore or Carelon.
Medicare requires documented CED study enrollment rather than conventional PA.
Conservative Document a failed course of conservative care (commonly at least 3 months): activity therapy modification, physical therapy, pharmacologic management, and often epidural steroid
injection.
Diagnostic block Not applicable. Candidacy is imaging- and symptom-driven (neurogenic claudication + LFH),
not block-confirmed.
Key documentation Neurogenic claudication; measured LFH (commonly at least 2.5 mm cited in consensus); up
to grade 2 spondylolisthesis; failed conservative care; functional impairment; correlated imaging.
Approval Best positioned as central-canal LSS driven by LFH in a candidate unsuitable for or wishing to considerations avoid open decompression; instability and disc-predominant or foraminal-predominant
stenosis undermine approval.
2. Overview
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Minimally Invasive Lumbar Decompression (MILD®) is a percutaneous, image-guided procedure that treats lumbar spinal stenosis (LSS) by removing hypertrophied ligamentum flavum and small portions of the lamina through a dorsal interlaminar approach. By debulking the thickened ligament, the procedure enlarges the central spinal canal and relieves the neural compression that produces neurogenic claudication. Because tissue is physically removed, MILD achieves a direct decompression — unlike interspinous spacers such as the Vertiflex® Superion system, which relieve symptoms through indirect decompression without removing tissue.
The procedure is typically performed in a hospital outpatient department or ambulatory surgery center under local anesthesia with sedation, without general anesthesia, implants, sutures, or overnight admission. These features make MILD attractive for older patients and those with comorbidities that increase the risk of open laminectomy or general anesthesia.
Two terms describe the same clinical procedure. MILD® is the branded device-and-technique name (Vertos Medical, acquired by Stryker in October 2024). Percutaneous Image-Guided Lumbar Decompression (PILD) is the generic term used by CMS in NCD 150.13. Throughout this guide the terms are used interchangeably; coding, coverage, and documentation requirements are identical.
Gohealthcare Clinical Insight
Why the branded and generic names both matter operationally Clinicians and device representatives speak in terms of “MILD.” Payers, MAC edits, and CMS policy speak in terms of “PILD.” Authorization and appeal letters land best when they bridge both vocabularies — name the MILD procedure, then cite NCD 150.13 (PILD) and the 2026 CPT® codes so the reviewer can reconcile the request against their own policy language immediately.
3. Relevant Anatomy (High-Level)
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Only the anatomy needed to understand candidacy, medical necessity, and documentation is summarized here; this guide is not a procedural or surgical manual.
- Central spinal canal. The bony-ligamentous channel housing the thecal sac and cauda equina.
Narrowing here is the target of MILD.
- Ligamentum flavum. The elastic ligament along the posterior canal. With age and degeneration it
thickens (hypertrophies), becoming a dominant contributor to central canal narrowing. It is the primary tissue MILD debulks.
- Lamina. The posterior bony arch. MILD removes only small portions to access and resect the
ligament; it does not perform a full laminectomy.
- Lateral recess and neural foramen. Where the traversing and exiting nerve roots travel.
Stenosis predominantly located here (rather than centrally) is generally not well addressed by MILD and is a candidacy red flag.
- Neurogenic claudication. The clinical hallmark of central LSS: position-dependent buttock and leg
pain, heaviness, or weakness that worsens with standing and walking and eases with sitting or flexion.
4. Clinical Indications
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MILD is indicated for the operational scenario summarized below. Candidacy is imaging- and symptom-driven.
- Lumbar spinal stenosis with neurogenic claudication as the predominant, functionally limiting
symptom.
- Central canal narrowing in which hypertrophied ligamentum flavum is a documented,
meaningful contributor (consensus literature frequently cites LFH at least 2.5 mm).
- Mild-to-moderate central stenosis rather than severe multifactorial or bony stenosis.
- Symptoms persisting despite an adequate trial of conservative care.
- Patients who prefer to avoid, or are poor candidates for, open laminectomy or general anesthesia.
5. Patient Selection
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Disciplined patient selection is the single strongest predictor of both clinical success and clean payer approval. The favorable and unfavorable profiles below should be reflected explicitly in the medical record.
Favorable candidate
- Neurogenic claudication that limits standing and walking tolerance and improves with flexion or
sitting.
- MRI or CT-myelogram showing central canal stenosis with clear ligamentum flavum hypertrophy.
- Stable spine or low-grade (up to grade 2) spondylolisthesis without dynamic instability.
- Documented failure of conservative management over a meaningful interval.
- Comorbidities or preference favoring a percutaneous, no-implant, no-general-anesthesia option.
Less favorable / reconsider
- Stenosis driven predominantly by disc herniation, bony osteophyte, or facet arthropathy rather than
LFH.
- Predominant lateral recess or foraminal (rather than central) stenosis.
- High-grade or dynamically unstable spondylolisthesis, or scoliosis-dominant deformity.
- Severe multilevel stenosis for which formal decompression is clearly indicated.
- Predominant axial back pain without neurogenic claudication.
6. Contraindications
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- Spinal instability, high-grade spondylolisthesis, or deformity requiring stabilization or fusion.
- Stenosis not attributable to ligamentum flavum hypertrophy (e.g., disc-predominant or purely bony
stenosis).
- Cauda equina syndrome or progressive neurologic deficit requiring urgent open decompression.
- Active local or systemic infection at the planned access site.
- Uncorrected coagulopathy or inability to safely stop anticoagulation per protocol.
- Inability to tolerate prone positioning or the procedural sedation plan.
7. Medical Necessity
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For MILD, the medical-necessity narrative must accomplish something more demanding than for most interventional procedures: it must not only establish the diagnosis and failed conservative care, but also confront the payer's frequent position that the procedure is investigational. Documentation should therefore make the clinical logic explicit and self-contained.
Elements that establish medical necessity
- Diagnosis with specificity: lumbar spinal stenosis with neurogenic claudication (ICD-10-CM
M48.062), correlated to symptoms and examination.
- Causal imaging: MRI or CT-myelogram documenting central canal stenosis with measurable
ligamentum flavum hypertrophy, ideally with the LFH measurement recorded.
- Functional impairment: objective limitation in standing and walking tolerance, with validated
measures where possible (e.g., pain scores, walking distance, disability index).
- Failed conservative care: dated history of physical therapy, pharmacologic management, and
(frequently) epidural steroid injection, with outcomes.
- Stability: confirmation that instability or high-grade listhesis is absent, addressing the primary
contraindication.
- Shared decision-making: rationale for a minimally invasive decompression over open surgery or
continued conservative care.
Gohealthcare Prior Authorization Insight
Medical necessity is written for a skeptical reader Because a meaningful share of commercial reviewers begin from an “investigational” default, the strongest necessity statements read as if the reviewer knows nothing favorable in advance. Lead with the LFH measurement and the neurogenic claudication findings, connect them causally, and cite society guidance (ASPN 2022; MIST 2.0). A necessity statement that merely asserts “the patient has stenosis and failed conservative care” invites the reviewer to fall back on the investigational label.
8. Imaging Requirements
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- Advanced imaging is required. MRI is preferred; CT-myelography is acceptable when MRI is
contraindicated.
- Imaging must demonstrate central canal stenosis and, critically, ligamentum flavum
hypertrophy as a contributor.
- Record the LFH measurement where feasible; consensus literature frequently references at least
2.5 mm.
- Imaging should be reasonably current and must correlate with the clinical presentation (claudication
distribution and level).
- Note any spondylolisthesis grade and the absence of dynamic instability; flexion-extension films
may support this.
- Intra-procedure fluoroscopy or CT provides the image guidance; it does not replace the diagnostic
study.
9. Conservative Treatment Requirements
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Nearly every payer pathway — and the clinical rationale itself — expects a documented, failed course of conservative management before decompression. Capture each modality with dates and outcomes.
Modality What to document
Activity modification / Counseling, ergonomic and gait strategies, assistive device use, dates and response.
education
Physical therapy Structured, supervised program (commonly at least 6 weeks); flexion-biased regimens;
measured functional change.
Pharmacologic NSAIDs, neuropathic agents, and analgesics as appropriate; response and tolerability.
management
Epidural steroid injection Often expected before decompression; document level(s), dates, and duration of any
relief.
Duration threshold Many policies expect at least 3 months of conservative care overall; verify the specific
plan.
10. CMS / Medicare Coverage
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Medicare coverage of MILD/PILD is unusual and must be understood precisely, because it drives the entire operational workflow for Medicare beneficiaries.
NCD 150.13 — Coverage with Evidence Development (CED)
- Traditional Medicare covers PILD only when furnished within a CMS-approved prospective
longitudinal study under the Coverage with Evidence Development pathway.
- The device must be FDA-approved or cleared, and the study must use a device that successfully
completed a CMS-approved randomized controlled trial meeting the Section 150.13 criteria.
- The study must address whether PILD produces clinically meaningful improvement in function
and/or reduction in pain versus other treatments in Medicare beneficiaries with LSS.
- Study sites and results must be registered on ClinicalTrials.gov and meet CMS standards of scientific
integrity.
- Outside an approved CED study, PILD is non-covered by traditional Medicare. This is the
most consequential coverage fact in this guide.
Claims and site-of-service notes
- Historically billed with 0275T under CED with specific claim conditions; for dates of service on or
after 01/01/2026 the service is reported with 62330 / +62331, and claim edits are being updated accordingly — confirm current MAC guidance.
- Recognized settings: hospital outpatient (POS 22, TOB 13X/85X) and ambulatory surgery center
(POS 24).
- G0276 remains a valid 2026 HCPCS code, but it is specific to the blinded/placebo-controlled arm of
an approved CED trial — not standard therapeutic reporting, which uses 62330 / +62331.
- Medicare Advantage plans may apply their own utilization management in addition to the NCD
framework; verify plan-specific rules.
Gohealthcare Prior Authorization Insight
The Medicare workflow is enrollment, not authorization For a Medicare beneficiary, the operational question is not “will the plan authorize this?” but “is this patient being treated within a qualifying CED study using a qualifying device?” Practices offering MILD to Medicare patients must confirm active study participation and the correct claim conditions before scheduling. Billing PILD to traditional Medicare outside CED is a compliance exposure, not merely a denial risk.
11. Commercial Payer Comparison
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Commercial coverage of image-guided MILD is genuinely fragmented, and this fragmentation — not the coding — is the dominant operational challenge. The synthesis below is directional; payer policies are revised frequently and vary by plan, product, and state. Always pull the member-specific medical policy before submitting.
Payer / UM vendor Typical posture (verify current policy)
eviCore (by Evernorth) Administers spine/pain UM for many national and regional plans; applies the delegating
plan's coverage stance and medical-necessity criteria.
Carelon Medical Administers spine/pain UM for numerous Blue and commercial plans; criteria and Benefits conservative-care expectations are enforced through its clinical guidelines.
Cohere Health Provides musculoskeletal UM for select plans; applies plan coverage determinations and
documentation criteria.
Evolent (formerly NIA) Musculoskeletal/interventional-pain UM for certain plans; applies delegated criteria.
UnitedHealthcare Maintains a medical policy addressing image-guided minimally invasive decompression;
historically restrictive for MILD — confirm current version.
Aetna Publishes a clinical policy bulletin addressing MILD/PILD; has historically applied an
investigational posture — confirm current bulletin.
Cigna Coverage policy addresses percutaneous lumbar decompression; UM frequently
delegated to eviCore — confirm current policy.
Humana Medical coverage policy addresses percutaneous image-guided decompression; verify
current criteria and Medicare Advantage overlay.
Blue Cross Blue Shield Independent plans vary; several evidence reviews classify image-guided MILD as plans investigational for LSS — check the specific plan.
Molina / Medicaid MCOs Publish clinical policies; Medicaid coverage is state- and plan-specific and often
restrictive.
Bottom line: for many commercial members MILD is denied as experimental / investigational; where it is covered, approval hinges on the same clinical pillars (neurogenic claudication, documented LFH, failed conservative care, absence of instability). The practical skill is knowing, per plan, whether the pathway is “criteria-based approval” or “policy-level exclusion,” because the two demand entirely different submission strategies.
12. Prior Authorization Workflow
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A disciplined, front-loaded workflow prevents the avoidable denials that dominate this procedure.
Step Action Owner
1. Verify benefits & Confirm the member's plan, UM vendor, and whether MILD is covered, PA / front policy criteria-based, or excluded as investigational. office
2. Confirm Neurogenic claudication + imaging-documented LFH; screen out instability Clinical indication and disc/foraminal-predominant stenosis.
3. Assemble Imaging report with LFH, conservative-care timeline, functional measures, PA + evidence packet medical-necessity statement. clinical
4. Confirm Medicare For traditional Medicare, confirm qualifying CED study enrollment and device PA / pathway before scheduling. compliance
5. Submit to correct Route to eviCore, Carelon, Cohere, Evolent, or the plan per delegation; use the PA entity current portal.
6. Track & respond Monitor status; answer clinical pends within the deadline; prepare for PA
peer-to-peer.
7. Authorization & Record the auth number, approved code(s) and level(s), validity dates; PA / scheduling schedule with matching documentation. scheduling
8. Denial pathway If denied, launch appeal or peer-to-peer immediately with a targeted rebuttal. PA /
physician
13. Common Prior Authorization Denials
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Denial reason Root cause Prevention
Investigational / Plan policy excludes MILD Confirm policy posture first; where excluded, pursue
experimental for LSS regardless of medical-necessity exception or appeal, not a standard
documentation. request.Insufficient Missing or undated PT, Provide a dated conservative-care timeline with outcomes. conservative care medication, or injection
history.
No documented LFH Imaging report does not Quote/measure the LFH from the MRI or CT-myelogram in the
identify ligamentum flavum request.hypertrophy.
Wrong stenosis Stenosis is disc-, bony-, or Select only central, LFH-driven cases; document mechanism mechanism foraminal-predominant. explicitly.
Instability present Higher-grade or dynamic Screen out; document stability with flexion-extension
listhesis noted. imaging.Medicare non-CED PILD billed to traditional Confirm study enrollment and claim conditions before billing Medicare outside a CED service.
study.
Coding mismatch Legacy 0275T after deletion, Use 62330 / +62331 for dates of service in 2026 onward.
or 62380 (endoscopic) used in error.
14. Appeal Strategies
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Appeals succeed when they are matched to the denial type. A criteria denial and a policy-exclusion denial require different arguments.
- For criteria-based denials: supply the missing element directly — the LFH measurement, the
dated conservative-care course, the stability confirmation — and map each to the plan's own criteria.
- For investigational denials: argue medical necessity and cite society guidance (ASPN 2022 Grade
A; MIST 2.0) and the peer-reviewed evidence base (MiDAS ENCORE; MOTION); request a medical-necessity exception where the benefit allows.
- Request peer-to-peer strategically: prepare the treating physician with the LFH value,
claudication findings, conservative-care timeline, and the specific guideline citations before the call.
- Escalate methodically: use the plan's internal levels, then external / independent review; for
Medicare Advantage, follow the CMS appeal timeline.
- Close the loop: feed each overturned denial back into the intake checklist so the same gap is not
repeated.
Gohealthcare Prior Authorization Insight
The best appeal is the one you do not have to file GoHealthcare's denial data on decompression procedures repeatedly shows that the elements most often missing at first submission — an explicit LFH measurement and a dated conservative-care timeline — are precisely the elements that overturn the denial on appeal. Moving those two items to the front of intake converts a large share of would-be appeals into first-pass approvals and avoids the peer-to-peer entirely.
15. Coding & Billing Overview
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This is an operational coding snapshot, not a full reimbursement methodology. The single most important message for 2026 is that the code changed: the Category III code 0275T was deleted effective 12/31/2025 and replaced by Category I codes 62330 and +62331.
Applicable CPT® codes (effective 01/01/2026)
CPT® Operational description (paraphrased) Notes
62330 Percutaneous lumbar decompression with partial removal of the Primary code.
ligamentum flavum, including laminotomy for access, epidurography, and Inherently bilateral —
image guidance; bilateral, one interspace. do not appendmodifier 50.
+62331 Same service, each additional lumbar interspace. Add-on to 62330;
reportable once per session regardless of number of additional levels.
0275T Prior Category III code for the same service. DELETED 12/31/2025.
Do not use for 2026 dates of service.
62380 Endoscopic lumbar decompression (direct visualization). Different procedure. A
common miscoding trap — MILD is percutaneous/indirect, not endoscopic.
0274T Percutaneous cervical/thoracic decompression. Non-lumbar regions
retain Category III coding; no Category I lumbar-equivalent for those regions.
HCPCS
- G0276 — a valid 2026 HCPCS code specific to the blinded/placebo-controlled arm of an approved
PILD CED trial; it is not used for standard therapeutic reporting (use 62330 / +62331). No implant HCPCS applies because MILD places no device.
Common ICD-10-CM diagnosis codes
ICD-10-CM Description Billing note
M48.062 Spinal stenosis, lumbar region, with neurogenic claudication. Primary supporting
diagnosis for MILD candidacy.
M48.061 Spinal stenosis, lumbar region, without neurogenic claudication. Use when
claudication is not documented.
M48.06 Spinal stenosis, lumbar region (unspecified). NON-BILLABLE
parent — will be rejected. Requires 6th-character specificity (M48.061 / M48.062).
M48.07 Spinal stenosis, lumbosacral region. Use per documented
level.
Modifiers, place of service, and ASC considerations
- Modifier 50: not applicable to 62330 — the descriptor is already bilateral.
- Modifier 52 (reduced services) may apply if the intended service is not completed; document
rationale.
- Place of service: 22 (hospital outpatient) or 24 (ambulatory surgery center); TOB 13X/85X for
facility claims.
- ASC: confirm the code is on the ASC-payable list for the payer and that device-intensive/packaging
rules are handled correctly.
- Documentation supporting code selection: interspace level(s) treated, ligamentum flavum
resection, image-guidance modality, and laterality context. CPT® is a registered trademark of the American Medical Association. Code descriptions here are paraphrased for operational use; consult the current CPT® code set and payer policy for official language.
16. Device Manufacturers & System Considerations
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MILD is a device-enabled but implant-free procedure. Understanding this distinction is important for coding, coverage, and patient counseling.
Attribute Detail
Manufacturer Vertos Medical, Inc. (acquired by Stryker Corporation, effective October 1, 2024).
System mild® Device Kit — a sterile, single-use set of specialized instruments (portal, trocar,
depth guide, bone sculpter/rongeur, tissue sculpter, surgical clamp).
FDA status 510(k)-cleared instrumentation for percutaneous lumbar decompression; not a permanent
implant.
Mechanism Dorsal interlaminar access; removal of small lamina portions and debulking of
hypertrophied ligamentum flavum under image guidance.
Implant / MRI None. Because no device is left in the body, there is no implant HCPCS code and no conditionality MRI-conditional labeling to manage post-procedure.
Coverage linkage The Medicare CED pathway (NCD 150.13) is tied to an FDA-approved/cleared device that
completed a qualifying CMS-approved RCT.
Gohealthcare Clinical Insight
Implant-free is a genuine differentiator — use it In patient counseling and in payer narratives, the absence of an implant is a real advantage: no hardware, no MRI-conditional device to track, no implant-related revision pathway. When comparing MILD to interspinous spacers (which are permanent implants) or to fusion, this distinction belongs in the record — it supports both the clinical rationale and the value argument.
17. Clinical Documentation Checklist
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Every item below should be present and dated in the record before submission.
- ☐ Neurogenic claudication described (standing/walking-provoked, flexion-relieved).
- ☐ Pain scores and functional impairment (walking tolerance, disability measure).
- ☐ Duration of symptoms.
- ☐ MRI or CT-myelogram report documenting central canal stenosis.
- ☐ Ligamentum flavum hypertrophy identified and, where feasible, measured.
- ☐ Spondylolisthesis grade and confirmation of stability (± flexion-extension films).
- ☐ Conservative-care timeline: physical therapy, medications, injections — with dates and
outcomes.
- ☐ Confirmation that stenosis mechanism is central and LFH-driven (not
disc/foraminal-predominant).
- ☐ Medical-necessity statement tying findings to the requested procedure.
- ☐ For Medicare: documented CED study enrollment and qualifying device.
- ☐ Correct 2026 coding recorded (62330 / +62331; M48.062).
18. Procedure Comparison
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MILD sits on a spectrum of options for LSS with neurogenic claudication. The comparison clarifies where it fits and why candidacy matters.
Option Mechanism Implant 2026 CPT® Best fit
MILD / PILD Direct: debulk None 62330 / Central LSS driven by LFH; avoid open
hypertrophied +62331 surgeryligamentum flavum
Interspinous spacer Indirect: Permane 22869 / Moderate LSS, claudication relieved (Vertiflex® extension-blocking nt +22870 by flexion Superion) spacer
coflex® Stabilization after open Permane 22867 / After laminectomy where stabilization interlaminar device decompression nt +22868 is desired
Epidural steroid Anti-inflammatory, None (injection Symptom control; conservative-care injection non-structural codes) step
Open / MIS Direct bony + None 63047, etc. Severe or multifactorial stenosis
laminectomy ligamentous (unless
decompression fused)Each of the interspinous-spacer options above is developed in its own dedicated guide within this Minimally Invasive Spine Procedures batch (Vertiflex®; Interspinous Spacer Procedures).
19. GoHealthcare Clinical Insights
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Gohealthcare Clinical Insight
Operational lessons from supporting minimally invasive decompression Lead every packet with the two decisive facts. The LFH measurement and the dated conservative-care timeline do more work than any other elements. Put them first, not buried in the imaging appendix. Separate ‘covered-with-criteria’ plans from ‘excluded’ plans at intake. Submitting a standard request to a plan that excludes MILD as investigational wastes a cycle and starts the clock over. Route excluded plans straight to a medical-necessity exception or appeal strategy. Guard the Medicare pathway. For traditional Medicare, verify CED study enrollment before scheduling; this is a compliance control, not a billing preference. Update the code tables now. Any residual 0275T logic in the EHR, charge master, or authorization templates will misfire in 2026. Confirm 62330 / +62331 are mapped and that 62380 is not being auto-suggested.
20. GoHealthcare Leadership Perspective
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Gohealthcare Leadership Perspective
Governing a procedure with a fragmented coverage landscape MILD is a case study in why payer intelligence, not clinical enthusiasm, should govern scheduling. The procedure is clinically reasonable for a well-defined patient, yet its coverage is fractured across Medicare's CED constraint and a patchwork of commercial positions ranging from criteria-based approval to outright exclusion. The organizations that succeed treat coverage verification as a gating step: they confirm the pathway before the patient is scheduled, they template the medical-necessity narrative so it is consistent and defensible, and they maintain a living map of which payers exclude the procedure and which merely apply criteria. There is also a compliance dimension that leadership must own directly. Billing PILD to traditional Medicare outside an approved CED study is not a gray area; it is a documented non-coverage. A disciplined MSO builds the CED verification into the workflow and audits for it. Handled this way, MILD becomes a predictable, defensible service line rather than a denial-and-write-off generator — and the same discipline transfers directly to the next generation of minimally invasive procedures entering the coverage debate.
21. GoHealthcare Prior Authorization Insight
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Gohealthcare Prior Authorization Insight
What a national MSK MSO knows that the policy language does not tell you Know the delegation before you know the criteria. The first question is not ‘what are the criteria’ but ‘who actually decides.’ The same insurer may route MILD to eviCore, Carelon, Cohere, or Evolent depending on product and region, and each applies the delegated policy through its own portal and clinical templates. Write the imaging into the request, not just attach it. Reviewers move fast; a request that states the measured LFH and the central-canal finding in the narrative is adjudicated faster than one that expects the reviewer to derive it from a PDF. Pre-empt the mechanism challenge. The most common substantive denial after ‘investigational’ is ‘stenosis not ligamentum-flavum driven.’ State the mechanism affirmatively. Prepare the peer-to-peer before it is offered. Have the physician armed with the LFH value, claudication findings, conservative-care dates, and the ASPN/MIST citations so the call resolves in one pass.
22. GoHealthcare Case Study
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An original, de-identified educational scenario. No real patient or organization is depicted.
Clinical scenario A 74-year-old with progressive neurogenic claudication reports walking tolerance reduced to roughly one block, relieved by leaning on a shopping cart. MRI shows moderate central canal stenosis at L3-L4 and L4-L5 with prominent ligamentum flavum hypertrophy and no more than grade 1 spondylolisthesis. The patient has completed physical therapy and two epidural steroid injections with only transient relief and wishes to avoid open surgery and general anesthesia given cardiac comorbidity.
Documentation challenges The MRI narrative described ‘multilevel degenerative change’ without isolating the ligamentum flavum as the dominant contributor, and the conservative-care history was scattered across three notes without a consolidated timeline.
Prior authorization barriers The commercial plan delegated review to a UM vendor whose policy treated image-guided MILD restrictively. The initial submission returned a pend requesting proof of ligamentum flavum involvement and a consolidated conservative-care record.
Payer considerations & workflow The team pulled the exact LFH measurement from the imaging, assembled a single dated conservative-care timeline, and rewrote the medical-necessity statement to name the mechanism (central, LFH-driven), confirm stability, and cite society guidance. The request was re-routed through the correct vendor portal with the imaging findings stated in the narrative.
Resolution & outcome The revised submission was approved without a peer-to-peer. The procedure was performed in the ASC (POS 24) and coded 62330 with +62331 for the second interspace. The patient reported improved walking tolerance at follow-up.
Lessons learned
- The denial was a documentation gap, not a clinical one — the facts existed but were not surfaced.
- Naming the mechanism (LFH-driven central stenosis) pre-empted the most likely substantive
objection.
- Consolidating conservative care into one dated timeline converted a pend into an approval.
- Correct 2026 coding (62330 / +62331, not 0275T or 62380) kept the clean claim clean.
23. GoHealthcare Best Practices
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- Verify coverage posture (covered-with-criteria vs. excluded) before scheduling.
- Template the medical-necessity narrative so LFH, claudication, and conservative care are always
present.
- Record the LFH measurement in the request narrative, not only the attached imaging.
- For Medicare, gate scheduling on confirmed CED study enrollment and a qualifying device.
- Map 62330 / +62331 in the EHR and charge master; retire 0275T logic; suppress 62380
auto-suggestions.
- Maintain a payer matrix of delegation (eviCore / Carelon / Cohere / Evolent) by plan and product.
- Feed every overturned denial back into the intake checklist.
24. Common Mistakes
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- Using deleted 0275T for 2026 dates of service, or miscoding MILD as endoscopic 62380.
- Appending modifier 50 to 62330 (already bilateral).
- Submitting M48.06 (non-billable parent) instead of M48.061 / M48.062.
- Omitting the ligamentum flavum finding, leaving the mechanism unproven.
- Treating a policy-exclusion denial as if it were a criteria denial (and vice versa).
- Billing PILD to traditional Medicare outside a CED study.
- Selecting patients with disc-, bony-, or foraminal-predominant stenosis or instability.
25. Pearls and Pitfalls
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Pearls & Pitfalls
High-yield reminders Pearl: The LFH measurement is the center of gravity of the entire request — protect it and lead with it. Pearl: ‘MILD’ for clinicians, ‘PILD / NCD 150.13’ for payers — speak both languages in one letter. Pitfall: Assuming commercial coverage because Medicare has an NCD — the NCD is a CED constraint, not a green light, and commercial policies frequently exclude. Pitfall: Leaving legacy 0275T logic active in 2026 systems. Pitfall: Conflating MILD (direct, tissue removal, no implant) with interspinous spacers (indirect, permanent implant) — different codes, coverage, and counseling.
26. Frequently Asked Questions
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Q1. Is MILD the same as PILD? Yes. MILD is the branded device-and-technique name; PILD is the generic term CMS uses in NCD 150.13. The clinical procedure, coding, and documentation requirements are identical. Q2. What CPT® code is used for MILD in 2026? 62330 for the first lumbar interspace and add-on +62331 for each additional interspace. These replaced Category III 0275T, which was deleted effective 12/31/2025. Q3. Can I still bill 0275T? No. 0275T should not be used for dates of service on or after 01/01/2026. Systems still mapped to 0275T must be updated. Q4. Is 62380 a valid alternative code for MILD? No. 62380 describes endoscopic decompression under direct visualization. MILD is percutaneous under indirect image guidance and is a common miscoding trap. Q5. Does Medicare cover MILD? Only under Coverage with Evidence Development per NCD 150.13 — the beneficiary must be enrolled in a CMS-approved prospective longitudinal study using a qualifying device. Outside CED, traditional Medicare does not cover it. Q6. Do commercial plans cover MILD? It varies widely. Many national plans classify image-guided MILD as experimental / investigational for LSS; some cover under specific criteria. Always verify the member-specific policy. Q7. What diagnosis code supports MILD? Most commonly M48.062 (lumbar spinal stenosis with neurogenic claudication). Never submit the non-billable parent M48.06. Q8. Is an implant placed during MILD? No. MILD removes tissue (ligamentum flavum and small lamina portions). No permanent device is implanted, so no implant HCPCS code applies. Q9. How is MILD different from the Vertiflex® procedure? MILD achieves direct decompression by removing tissue; Vertiflex® (Superion) is a permanent interspinous spacer providing indirect decompression. They use different CPT® codes and coverage pathways. Q10. What imaging is required? MRI (preferred) or CT-myelogram documenting central canal stenosis with ligamentum flavum hypertrophy, correlated to the clinical presentation. Q11. What is the ligamentum flavum measurement threshold? Consensus literature frequently references LFH at least 2.5 mm as a meaningful contributor; record the measurement where feasible. Confirm any plan-specific threshold. Q12. How much conservative care is expected? Commonly at least three months of physical therapy, medications, and often epidural steroid injection, documented with dates and outcomes; verify the specific policy. Q13. Is a diagnostic block required? No. Candidacy is imaging- and symptom-driven, not confirmed by a diagnostic block.
Q14. Which UM vendor reviews MILD? Depending on plan and region, eviCore, Carelon, Cohere, or Evolent may administer review. Identify the delegated entity before submitting. Q15. What is the most common denial reason? An investigational / experimental policy exclusion, followed by insufficient conservative care and undocumented ligamentum flavum involvement. Q16. What place of service applies? Hospital outpatient (POS 22) or ambulatory surgery center (POS 24); facility claims use TOB 13X or 85X. Q17. Is MILD performed under general anesthesia? Typically no — it is usually performed under local anesthesia with sedation, which is part of its appeal for higher-risk patients. Q18. What is G0276? A HCPCS code, still valid in 2026, that is specific to the blinded/placebo-controlled arm of an approved PILD CED trial. It is not used for standard therapeutic MILD, which is reported with 62330 / +62331. Q19. Does spondylolisthesis disqualify a patient? High-grade or dynamically unstable listhesis is a contraindication. Low-grade (up to grade 2), stable listhesis may still be appropriate; document stability. Q20. Can MILD and an interspinous spacer be considered for the same patient? They address overlapping indications differently. Selection depends on mechanism, stability, and payer coverage; they are evaluated as distinct procedures with distinct policies. Q21. How should an investigational denial be appealed? Argue medical necessity with the LFH and claudication findings, cite ASPN 2022 and MIST 2.0 and the RCT evidence, and request a medical-necessity exception where the benefit permits. Q22. What single change most improves approval rates? Moving the LFH measurement and a consolidated, dated conservative-care timeline to the front of the request.
27. Key Takeaways
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- MILD and PILD are the same procedure: percutaneous, image-guided debulking of hypertrophied
ligamentum flavum, no implant.
- 2026 coding: 62330 / +62331 replaced deleted 0275T; 62380 (endoscopic) is a miscoding trap.
- Medicare covers PILD only under CED (NCD 150.13); outside a qualifying study it is non-covered.
- Commercial coverage is fragmented — frequently investigational; verify the member policy and the
UM delegate first.
- The decisive documentation is the measured ligamentum flavum hypertrophy plus a dated
failed conservative-care timeline.
- Match the appeal to the denial: criteria gap vs. policy exclusion require different strategies.
28. Future Outlook
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The transition of MILD/PILD from a Category III to a Category I code family in 2026 signals maturation of the procedure's place in the coding system, even as coverage remains contested. Expect continued accumulation of comparative evidence — including the ongoing Medicare claims work — to pressure
commercial policies over time, and expect UM vendors to refine criteria rather than maintain blanket exclusions as the code stabilizes. Practices should anticipate periodic policy revisions, monitor MAC operationalization of the new codes within the CED framework, and watch for convergence between MILD and interspinous-spacer pathways as minimally invasive options for lumbar spinal stenosis are increasingly evaluated side by side.
29. References
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- Centers for Medicare & Medicaid Services. NCD 150.13 — Percutaneous Image-Guided Lumbar Decompression
for Lumbar Spinal Stenosis. https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=358
- Centers for Medicare & Medicaid Services. Decision Memo CAG-00433R (PILD for LSS).
https://www.cms.gov/medicare-coverage-database
- American Medical Association. CPT® 2026 code set (62330, +62331; deletion of 0275T).
https://www.ama-assn.org/practice-management/cpt
- AAPC. CPT® 2026 update summary (percutaneous ligamentum flavum decompression).
https://www.aapc.com/blog/93606-cpt-2026-the-wait-is-over/
- Deer TR, et al. Best Practices for Minimally Invasive Lumbar Spinal Stenosis Treatment 2.0 (MIST). Pain Pract.
2019;19(3):250-274. PMID 30369003.
- Deer TR, et al. The MOTION Study: RCT of the mild® procedure for LSS — one-year results. Pain Med.
2022;23(4):625-634. PMID 35167700. https://pmc.ncbi.nlm.nih.gov/articles/PMC8992575/
- Deer TR, et al. The MOTION Study: two-year results of a real-world RCT of the mild® procedure for LSS. Pain
Pract. 2024;24(1):109-119. PMID 37661347. https://onlinelibrary.wiley.com/doi/10.1111/papr.13293
- Staats PS, et al. PILD and outpatient laminectomy for LSS: a 2-year Medicare claims benchmark study. Interv Pain
Med. 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC11373052/
- Yuan H, Yi X. Lumbar Spinal Stenosis and Minimally Invasive Lumbar Decompression: A Narrative Review. J Pain
Res. 2023;16:3707-3724. https://pmc.ncbi.nlm.nih.gov/articles/PMC10637222/
- North American Spine Society. Evidence-Based Clinical Guidelines: Diagnosis and Treatment of Degenerative
Lumbar Spinal Stenosis. https://www.spine.org
- ICD-10-CM 2026: M48.061 / M48.062 (lumbar spinal stenosis).
https://www.cms.gov/medicare/coding-billing/icd-10-codes
- Stryker Corporation. Acquisition of Vertos Medical, Inc. (2024). https://www.stryker.com
- U.S. Food & Drug Administration. 510(k) Premarket Notification database.
https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm
30. Reading Recommendations
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- CMS NCD 150.13 and the CAG-00433R decision memo — the authoritative Medicare coverage
framework.
- ASPN 2022 consensus and MIST 2.0 — society guidance on patient selection and appropriateness.
- MiDAS ENCORE and MOTION trials — the core comparative evidence cited in appeals.
- Your top commercial plans' current medical policies for image-guided minimally invasive
decompression.
31. Related GoHealthcare Resources (Internal Links)
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- Vertiflex® Procedure — Guide 02 of this Minimally Invasive Spine batch.
- Interspinous Spacer Procedures — Guide 04 of this batch.
- GoHealthcare Prior Authorization Knowledge Center (spine & interventional pain).
- GoHealthcare Revenue Cycle Knowledge Center (coding, edits, and appeals).
- Website: https://www.gohealthcarellc.com
32. Recommended Downloads
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- MILD/PILD medical-necessity statement template.
- Conservative-care timeline worksheet.
- Payer delegation matrix (eviCore / Carelon / Cohere / Evolent) by plan.
- 2026 coding quick-card (62330 / +62331; M48.062).
33. Visual Recommendations
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- High-level lumbar canal anatomy illustration highlighting ligamentum flavum hypertrophy.
- Prior authorization workflow process map (intake → submission → decision → appeal).
- Coverage matrix comparing Medicare CED vs. commercial postures.
- Decision tree for MILD vs. interspinous spacer vs. laminectomy candidacy.
- Documentation checklist infographic.
34. Document History
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Version Date Summary
1.0 2026 Initial publication under GoHealthcare Clinical Procedure Guide Standard v1.0. Reflects
2026 CPT® transition (62330/+62331), NCD 150.13 CED framework, and current commercial-payer landscape.
35. Educational Disclaimer
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This document is part of the GoHealthcare Practice Solutions Knowledge Center and is intended for educational and operational reference purposes only. It is not a physician training manual, procedural technique guide, clinical textbook, or legal advice, and it does not replace physician clinical judgment, payer policy review, or official CMS guidance. It is not a substitute for specialty society procedural training. Coverage policies, coding guidance, and reimbursement requirements change frequently and vary by payer, product, plan, and jurisdiction; they must always be verified against the applicable payer policy and current regulatory sources before clinical or billing decisions are made. CPT® is a registered trademark of the American Medical Association. Product and company names are the property of their respective owners and are referenced for identification only.
Developed by Pinky Maniri
Founder & Chief Executive Officer, GoHealthcare Practice Solutions
National Musculoskeletal Specialty Management Services Organization (MSO)