MINIMALLY INVASIVE SPINE PROCEDURES · GUIDE 03 OF 04
Percutaneous Image-Guided
Lumbar Decompression (PILD) Medicare Coverage, NCD 150.13, and the Coverage with Evidence Development Pathway The CMS coverage lens on the procedure marketed as MILD®
PILD is the term the Centers for Medicare & Medicaid Services uses for the same procedure that is marketed clinically as MILD. This guide is the coverage-and-compliance companion to the MILD guide (Guide 01): it concentrates on Medicare's unusual coverage structure under National Coverage Determination 150.13, the Coverage with Evidence Development (CED) requirement, the claim conditions that make a CED claim payable, and the compliance exposure created when the procedure is billed outside a qualifying study. For device, clinical, and general coding detail, see the MILD guide.
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 is coverage-forward, because coverage is what distinguishes PILD from every other procedure in this batch. Every entry is expanded and sourced later in this guide.
Domain Summary
Procedure Percutaneous, image-guided debulking of hypertrophied ligamentum flavum (with small
lamina removal) to decompress the central lumbar canal. No implant is placed. Identical to the procedure marketed as MILD.
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 a qualifying FDA-approved/cleared device.
CED claim conditions A payable CED claim carries ICD-10 Z00.6, Condition Code 30, and an 8-digit CMS
clinical-trial identifier. Claims from hospitals not participating in the approved study/registry are rejected.
Outside CED Traditional Medicare does not cover PILD outside an approved study. Billing it as a routine
covered service is a compliance exposure, not merely a denial risk.
Commercial Fragmented and largely unfavorable. Many national plans classify image-guided PILD/MILD coverage as experimental/investigational; utilization management is often delegated to eviCore,
Carelon, Cohere, or Evolent.
Evidence level MiDAS ENCORE (PILD vs epidural steroid injection) and the MOTION randomized trial
support the procedure; several payer evidence reviews rate the comparative evidence as low quality, which is the source of the coverage split.
Image guidance Required. Fluoroscopy or CT with epidurography; pre-procedure MRI or CT-myelogram must
document central stenosis with ligamentum flavum hypertrophy.
Conservative A failed course of conservative care (commonly at least 3 months) is expected: activity therapy modification, physical therapy, pharmacologic management, and often epidural steroid
injection.
Diagnostic block Not applicable. Candidacy is imaging- and symptom-driven (neurogenic claudication plus
ligamentum flavum hypertrophy).
Coding (2026) 62330 (first interspace) and add-on +62331 (each additional), effective 01/01/2026; these
replaced deleted Category III 0275T. G0276 remains valid for the blinded/placebo arm of a CED trial.
Key documentation Study enrollment and trial identifier; neurogenic claudication; measured ligamentum flavum
hypertrophy; failed conservative care; functional impairment; correlated imaging.
2. Overview
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Percutaneous Image-Guided Lumbar Decompression (PILD) is the name CMS uses for the minimally invasive, image-guided procedure that removes hypertrophied ligamentum flavum and a small portion of lamina to enlarge the central lumbar canal in patients with neurogenic claudication. It is performed under indirect image guidance without direct visualization of the surgical field, and it places no implant. Clinically, the same procedure is marketed as MILD (minimally invasive lumbar decompression). The two terms describe one procedure viewed from two vantage points: MILD is the device/clinical brand, and PILD is the CMS coverage term.
This guide exists because PILD's coverage structure is unlike anything else in the minimally invasive spine portfolio and deserves a dedicated, coverage-focused reference. Rather than repeat the device, anatomy, and general coding content already developed in the MILD guide, this page concentrates on the operational core of PILD: the National Coverage Determination, the Coverage with Evidence Development requirement, and the exact claim conditions and compliance boundaries that determine whether a Medicare claim is payable. Clinical and device sections here are intentionally concise and cross-reference the MILD guide.
3. Relevant Anatomy (High-Level)
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The operative target is the hypertrophied ligamentum flavum, which in degenerative lumbar spinal stenosis thickens and encroaches on the central canal, compressing the cauda equina and producing neurogenic claudication that worsens with standing and walking and improves with flexion. PILD debulks that ligament and a small portion of adjacent lamina to restore central canal volume. Anatomy is limited here to what drives candidacy and coverage; the MILD guide carries the fuller anatomic discussion.
4. Clinical Indications
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- Neurogenic claudication secondary to central lumbar spinal stenosis with documented ligamentum
flavum hypertrophy as a primary contributor.
- Symptoms that improve with flexion and worsen with extension, consistent with central stenosis.
- Persistent, function-limiting symptoms after a reasonable course of conservative care.
- For Medicare coverage specifically: the beneficiary must additionally be enrolled in a
CMS-approved CED study — clinical appropriateness alone does not create Medicare coverage. See the MILD guide for the detailed clinical-selection discussion; the distinguishing requirement on this page is study enrollment as a condition of Medicare coverage.
5. Patient Selection
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- Central, ligamentum-flavum-driven stenosis rather than disc-, bony-, or foraminal-predominant
stenosis.
- Neurogenic claudication with a positional pattern; up-to-Grade-1 (stable) spondylolisthesis at most.
- Failed conservative care with persistent functional limitation.
- A patient who is unsuitable for or wishes to avoid open decompression.
- For Medicare: willingness and ability to enroll and be followed within a CMS-approved study.
6. Contraindications
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- Stenosis that is disc-, bony-, or foraminal-predominant rather than ligamentum-flavum-driven.
- Greater-than-Grade-1 spondylolisthesis or dynamic instability.
- Severe stenosis or cauda equina syndrome requiring open decompression.
- Active infection, uncorrected coagulopathy, or other standard contraindications to a percutaneous
spine procedure.
- For Medicare coverage: absence of enrollment in a qualifying CED study (a coverage
contraindication, not a clinical one).
7. Medical Necessity
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For PILD under Medicare, medical necessity has two layers that must both be satisfied. The clinical layer is the same as MILD — central, ligamentum-flavum-driven stenosis with neurogenic claudication and failed conservative care. The coverage layer is unique: the service is reasonable and necessary to Medicare only when furnished within a CMS-approved CED study using a qualifying device. A record that establishes clinical appropriateness but not study participation does not meet Medicare's coverage standard.
- Clinical necessity: neurogenic claudication; measured ligamentum flavum hypertrophy; correlated
imaging; failed conservative care; functional impairment.
- Coverage necessity (Medicare): documented enrollment in a CMS-approved CED study and the
qualifying clinical-trial identifier, with the correct claim conditions.
8. Imaging Requirements
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- Pre-procedure MRI or CT-myelogram documenting central canal stenosis with ligamentum flavum
hypertrophy.
- The ligamentum flavum finding named and, where possible, measured — it is the mechanism the
record must prove.
- Spondylolisthesis grade documented as no greater than Grade 1.
- Intra-procedure fluoroscopic or CT guidance with epidurography (bundled into 62330).
See the MILD guide for the fuller imaging-documentation discussion.
9. Conservative Treatment Requirements
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- A documented, dated course of conservative care (commonly at least 3 months): activity
modification, physical therapy, and pharmacologic management.
- Epidural steroid injection where used, with dates and degree/duration of relief.
- A clear statement that symptoms and functional limitation persisted despite the above.
10. CMS / Medicare Coverage
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This is the center of the guide. Medicare coverage of PILD is governed by National Coverage Determination 150.13, and it is structured differently from almost any other spine procedure: it is covered only inside a clinical study.
NCD 150.13 and the Coverage with Evidence Development pathway
- Under Section 1862(a)(1)(A), CMS determined that PILD for lumbar spinal stenosis is not
reasonable and necessary for general coverage.
- Under Section 1862(a)(1)(E), CMS covers PILD through Coverage with Evidence Development --
only when the beneficiary is enrolled in a CMS-approved prospective longitudinal study.
- The study must use an FDA-approved or cleared device that successfully completed a
CMS-approved randomized controlled trial meeting the Section 150.13 criteria.
- 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.
A brief coverage history
- January 9, 2014 (CAG-00433N): CMS issued the first NCD, covering PILD only within a prospective,
randomized, controlled trial under CED.
- December 7, 2016 (CAG-00433R reconsideration): CMS expanded coverage to a broader
prospective longitudinal study using a qualifying device, while keeping the CED requirement in place.
- The CED requirement remains in effect. A CED cycle ends only when CMS reconsiders and removes
study participation as a condition of coverage — which has not occurred for PILD.
The research questions a CED study must address
- Does PILD provide a clinically meaningful improvement in function and/or quality of life versus other
treatments?
- Does PILD provide a clinically meaningful reduction in pain versus other treatments?
- Does PILD affect the overall clinical management of LSS and decision-making versus other
treatments?
Claim conditions that make a CED claim payable
- ICD-10 Z00.6 — the clinical-trial diagnosis code (encounter for examination for normal comparison
and control in a clinical research program), in addition to the LSS diagnosis.
- Condition Code 30 — identifying a qualifying clinical-trial service.
- An 8-digit CMS clinical-trial identifier listed on the CMS Coverage with Evidence Development
registry.
- Recognized settings: hospital outpatient (POS 22, TOB 13X/85X) and ambulatory surgery center
(POS 24).
- Claims billed by hospitals not participating in the approved study/registry are rejected.
The blinded-arm code
- G0276 remains a valid 2026 HCPCS code specific to the blinded/placebo-controlled arm of an
approved CED trial. It is not used for standard therapeutic reporting, which is 62330 / +62331.
Gohealthcare Prior Authorization Insight
For Medicare, it is enrollment, not authorization The Medicare question on PILD is not ‘will the plan authorize this?’ but ‘is this beneficiary being treated within a qualifying CED study using a qualifying device, with the correct claim conditions?’ A practice offering PILD to Medicare patients must confirm active study participation, capture the 8-digit trial identifier, and apply Z00.6 and Condition Code 30 before scheduling. Billing PILD to traditional Medicare outside CED is a compliance exposure, not merely a denial risk — treat it as a hard gate, not a soft edit.
11. Commercial Payer Comparison
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Commercial coverage of image-guided PILD/MILD is fragmented and largely unfavorable. Many national plans classify the image-guided procedure as experimental or investigational for lumbar spinal stenosis, while a minority cover it under narrow criteria. Utilization management is frequently delegated to eviCore, Carelon, Cohere, or Evolent. The Medicare CED framework does not apply to commercial plans — a commercial request is a medical-necessity/coverage question, not a study-enrollment question. Always verify the member's specific plan and controlling policy version.
Payer / vendor Typical posture (verify current policy)
eviCore (delegated) Applies image-guided decompression criteria for several plans; frequently restrictive.
Confirm the current guideline version.
Carelon / Cohere / Where delegated, apply plan-specific criteria; posture ranges from investigational to Evolent criteria-based. Confirm per plan.
National commercial Several classify image-guided PILD/MILD as experimental/investigational for LSS; a plans minority cover under narrow criteria.
Medicare Advantage Applies the NCD 150.13 CED framework plus plan-level utilization management; verify
plan-specific rules.
The recurring commercial objection mirrors the Medicare rationale that produced CED in the first place: several evidence reviews rate the comparative evidence as low quality. Requests and appeals should therefore engage the evidence question directly and cite the strongest randomized data.
12. Prior Authorization Workflow
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The workflow branches on benefit type, because the Medicare pathway is a study-enrollment gate and the commercial pathway is a coverage/medical-necessity question.
Step Action Owner
1. Verify benefits & Identify plan and UM vendor; determine Medicare vs. commercial and the PA / front posture controlling coverage rule. office
2. Medicare CED Confirm the beneficiary is enrolled in a CMS-approved CED study with a PA / research gate qualifying device; capture the 8-digit trial identifier. coordinator
3. Commercial Determine covered / covered-with-criteria / excluded; assemble the PA pathway evidence packet accordingly.
4. Assemble Imaging with ligamentum flavum hypertrophy; dated conservative-care PA + clinical evidence packet timeline; functional measures; medical-necessity statement.
5. Submit to correct Route to the plan/vendor (commercial) or apply CED claim conditions PA entity (Medicare); use the current portal and policy version.
6. Track & respond Monitor status; answer clinical pends within the deadline; prepare for PA
peer-to-peer.
7. Schedule with the For Medicare, ensure Z00.6, Condition Code 30, and the trial identifier are PA / correct conditions on the claim; record approved codes/levels. scheduling
8. Denial pathway For commercial denials, appeal with the strongest randomized evidence; for PA / physician
Medicare, do not bill outside CED.
13. Common Prior Authorization Denials
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Denial / rejection Root cause Prevention
reason
Medicare CED claim Missing Z00.6, Condition Apply all CED claim conditions; confirm site participation rejected Code 30, or the 8-digit trial before scheduling.
identifier; hospital not in the approved study/registry.
Billed outside CED PILD billed to traditional Treat CED enrollment as a hard gate; do not schedule
Medicare as a routine Medicare patients outside a qualifying study.covered service.
Investigational / Commercial plan excludes Confirm posture first; where excluded, pursue a experimental image-guided PILD/MILD medical-necessity exception or appeal.
regardless of documentation.
No documented Imaging report does not Quote/measure the finding in the request narrative. ligamentum flavum name the ligamentum hypertrophy flavum as the mechanism.
Insufficient Missing or undated therapy, Provide a single dated conservative-care timeline with conservative care medication, or injection outcomes.
history.
Coding mismatch Legacy 0275T after deletion, Use 62330 / +62331 for 2026 dates of service.
or 62380 (endoscopic) used in error.
14. Appeal Strategies
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- For commercial investigational denials: argue medical necessity for the specific patient and cite
the strongest randomized evidence (MiDAS ENCORE; MOTION), acknowledging the evidence critique and requesting a medical-necessity exception where a categorical exclusion exists.
- For commercial criteria denials: supply the missing element directly — the ligamentum flavum
measurement, the dated conservative-care course — and map each to the plan's own criteria.
- For Medicare: the answer to a coverage problem is almost never an appeal — it is correcting the
CED claim conditions or confirming study participation. PILD billed outside CED should not be appealed into coverage; it should not be billed.
- Prepare peer-to-peer strategically: brief the physician with the ligamentum flavum finding,
claudication findings, and conservative-care timeline before the call.
- Close the loop: feed every overturned denial and every rejected CED claim back into the intake
checklist.
15. Coding & Billing Overview
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This is an operational coding snapshot, not a full reimbursement methodology. The 2026 coding is identical to the MILD guide; the PILD-specific layer is the CED claim conditions.
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.
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. PILD is percutaneous/indirect, not endoscopic.
HCPCS and CED claim conditions
- G0276 — valid 2026 HCPCS code specific to the blinded/placebo-controlled arm of an approved PILD
CED trial; not used for standard therapeutic reporting. No implant HCPCS applies because PILD places no device.
- ICD-10 Z00.6 plus the LSS diagnosis, Condition Code 30, and an 8-digit CMS clinical-trial
identifier are required on a Medicare CED claim.
- Place of service 22 (hospital outpatient, TOB 13X/85X) or 24 (ASC).
Common ICD-10-CM diagnosis codes
ICD-10-CM Description Billing note
M48.062 Spinal stenosis, lumbar region, with neurogenic claudication. Primary supporting
diagnosis.
M48.061 Spinal stenosis, lumbar region, without neurogenic claudication. Use when
claudication is not documented.
M48.07 Spinal stenosis, lumbosacral region. Use per documented
level.
Z00.6 Encounter for examination for normal comparison/control in a clinical Required CED trial
research program. code on Medicareclaims.
M48.06 Spinal stenosis, lumbar region (unspecified). NON-BILLABLE
parent — requires 6th-character specificity (M48.061 / M48.062).
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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- PILD/MILD places no implant; the mild® Device Kit (Vertos Medical, part of Stryker since October
2024) comprises single-use, FDA 510(k)-cleared instruments used to debulk the ligamentum flavum.
- Because there is no implant, there is no MRI-conditionality consideration and no device
HCPCS for the therapeutic procedure — a clean contrast with the interspinous spacer guides.
- CED device requirement: for Medicare coverage, the study must use an FDA-approved/cleared
device that successfully completed a CMS-approved RCT meeting the Section 150.13 criteria — so the device's regulatory and trial history is itself a coverage element. See the MILD guide (Guide 01) for the fuller device discussion.
17. Clinical Documentation Checklist
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- ☐ Neurogenic claudication documented, with positional pattern.
- ☐ Ligamentum flavum hypertrophy named (and measured where possible) on imaging.
- ☐ Spondylolisthesis grade documented as no greater than Grade 1.
- ☐ Dated conservative-care timeline with outcomes.
- ☐ Functional impairment recorded.
- ☐ Medicare: CED study enrollment confirmed and the 8-digit trial identifier captured.
- ☐ Medicare: Z00.6 and Condition Code 30 applied to the claim.
- ☐ Correct 2026 coding recorded (62330 / +62331; not 0275T or 62380).
- ☐ Benefit-type branch documented (Medicare CED vs. commercial).
18. Procedure Comparison
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Procedure Mechanism Implant Primary Medicare coverage posture
CPT®
PILD / MILD Direct: debulk None 62330 / Covered only under CED (NCD
ligamentum flavum +62331 150.13)Vertiflex / Indirect: interspinous Yes 22869 / No NCD/LCD; medical-necessity to Superion spacer +22870 FDA indication
coflex Interlaminar device WITH Yes 22867 / Plan/MAC dependent
decompression +22868Laminectomy Direct open No 63047 family Covered per standard surgical criteria
decompression
The comparison makes the point of this guide visible: PILD is the only option in the batch whose Medicare coverage is gated to a clinical study.
19. GoHealthcare Clinical Insights
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- Speak both languages in one record: ‘MILD’ for clinicians, ‘PILD / NCD 150.13 / CED’ for Medicare
claims.
- The ligamentum flavum finding is the clinical center of gravity — name it and, where possible,
measure it.
- For Medicare, treat study enrollment and the trial identifier as intake data captured before
scheduling, not paperwork chased afterward.
- Consolidate conservative care into one dated timeline.
- Do not let a commercial ‘investigational’ posture and the Medicare CED gate blur together — they
are different problems with different solutions.
20. GoHealthcare Leadership Perspective
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PILD is the clearest example in this batch of a procedure where the operational risk is not denial but compliance. Because traditional Medicare covers PILD only inside a CED study, a practice that bills it as a routine covered service is not merely risking a denial — it is billing a non-covered service, with the audit and repayment exposure that implies. For a leader, the governing principle is to convert the CED requirement into a hard operational gate: no Medicare PILD is scheduled without confirmed study enrollment, a captured trial identifier, and the correct claim conditions. Commercial cases are a separate, ordinary medical-necessity problem. Keeping those two pathways distinct — and refusing to let clinical appropriateness be mistaken for Medicare coverage — is what protects both the patient and the organization.
21. GoHealthcare Prior Authorization Insight
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Gohealthcare Prior Authorization Insight
The CED identifier is the whole ballgame for Medicare On Medicare PILD, the single most common and most consequential failure is a claim that is clinically perfect but missing a CED condition — no Z00.6, no Condition Code 30, or no 8-digit trial identifier — or worse, a claim from a site that is not enrolled in an approved study at all. The GoHealthcare standard is to verify site participation and capture the trial identifier at intake, and to hard-stop scheduling of any Medicare PILD that cannot produce it. This single control converts the highest-risk scenario in the batch into a routine one.
22. GoHealthcare Case Study
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Clinical scenario A 76-year-old Medicare beneficiary with neurogenic claudication has walking tolerance reduced to roughly one block, relieved by leaning forward. MRI shows moderate central canal stenosis at L3-L4 and L4-L5 with prominent ligamentum flavum hypertrophy and no more than Grade 1 spondylolisthesis. Physical therapy and two epidural steroid injections gave only transient relief, and the patient wishes to avoid open surgery.
Documentation and coverage challenges Clinically the patient is an appropriate PILD candidate. The obstacle is coverage: under NCD 150.13, traditional Medicare will not cover PILD unless the patient is treated within a CMS-approved CED study, and the practice had planned to schedule the case as a routine covered procedure.
Resolution strategy The team stopped the routine-scheduling pathway, confirmed the site's participation in a qualifying CED study, enrolled the beneficiary, and captured the 8-digit trial identifier at intake. The claim was built with the LSS diagnosis plus Z00.6 and Condition Code 30, coded 62330 with +62331 for the second interspace, in the hospital outpatient setting.
Outcome & lessons learned
- The claim was payable because the CED conditions were present; billed as a routine service, it would
have been non-covered.
- Study enrollment is a coverage prerequisite, not an afterthought — capturing it at intake prevented
a compliance problem.
- Correct 2026 coding (62330 / +62331, not 0275T or 62380) kept the clean claim clean.
- The clinical record and the coverage record are two different jobs; both had to be done.
23. GoHealthcare Best Practices
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- Gate Medicare PILD scheduling on confirmed CED study enrollment and a captured 8-digit trial
identifier.
- Build a claim template that applies Z00.6 and Condition Code 30 for CED claims automatically.
- Keep the MILD and PILD records aligned: same clinical facts, different coverage framing.
- Map 62330 / +62331 in the EHR and charge master; retire 0275T logic; suppress 62380
auto-suggestions.
- Maintain a payer matrix of commercial posture and delegation (eviCore / Carelon / Cohere / Evolent).
- Never appeal a Medicare PILD service into coverage outside CED — correct the conditions or do not
bill.
- Feed every rejected CED claim back into the intake checklist.
24. Common Mistakes
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- Billing PILD to traditional Medicare outside a CED study — a compliance exposure, not just a denial.
- Omitting Z00.6, Condition Code 30, or the 8-digit trial identifier on a Medicare CED claim.
- Using deleted 0275T for 2026 dates of service, or miscoding PILD as endoscopic 62380.
- Appending modifier 50 to 62330 (already bilateral).
- Submitting M48.06 (non-billable parent) instead of M48.061 / M48.062.
- Blurring the commercial ‘investigational’ problem with the Medicare CED gate.
- 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: For Medicare, the coverage question is enrollment, not authorization — capture the trial identifier at intake. Pearl: One record, two languages — ‘MILD’ for clinicians, ‘PILD / NCD 150.13 / CED’ for the Medicare claim. Pitfall: Assuming commercial coverage because an NCD exists — the NCD is a CED constraint, not a green light, and commercial plans frequently exclude the procedure. Pitfall: Billing PILD to traditional Medicare outside CED, or missing a CED claim condition. Pitfall: Using deleted 0275T or endoscopic 62380 for a 2026 date of service.
26. Frequently Asked Questions
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Q1. Is PILD the same procedure as MILD? Yes. PILD is the CMS coverage term; MILD is the clinical/device brand. Same procedure, same codes, same NCD. Q2. How does Medicare cover PILD? Only under Coverage with Evidence Development (NCD 150.13): the beneficiary must be enrolled in a CMS-approved prospective longitudinal study using a qualifying device. Q3. What happens if PILD is billed outside a CED study? Traditional Medicare does not cover it. Billing it as a routine covered service is a compliance exposure, not merely a denial. Q4. What claim conditions make a CED claim payable? ICD-10 Z00.6 plus the LSS diagnosis, Condition Code 30, and an 8-digit CMS clinical-trial identifier; the site must be participating in the approved study.
Q5. What is Z00.6? The clinical-trial diagnosis code — encounter for examination for normal comparison and control in a clinical research program — required on Medicare CED claims. Q6. What is Condition Code 30? A claim condition code identifying a qualifying clinical-trial service; it is required on Medicare PILD CED claims. Q7. What is the 8-digit clinical-trial identifier? A CMS-assigned identifier for the approved study, listed on the CMS Coverage with Evidence Development registry, that must appear on the claim. Q8. What CPT® code is used in 2026? 62330 for the first interspace and add-on +62331 for each additional interspace. These replaced Category III 0275T, deleted 12/31/2025. Q9. Is 62380 ever correct for PILD?
No. 62380 is endoscopic (direct-visualization) decompression, a different procedure. PILD is
percutaneous/indirect. Q10. What is G0276? A HCPCS code, still valid in 2026, specific to the blinded/placebo-controlled arm of an approved PILD CED trial. It is not used for standard therapeutic PILD. Q11. Does the CED requirement still apply in 2026? Yes. A CED cycle ends only when CMS reconsiders and removes study participation as a condition of coverage, which has not occurred for PILD. Q12. When was the NCD issued and revised? The initial NCD was posted January 9, 2014 (CAG-00433N); a 2016 reconsideration (CAG-00433R), effective December 7, 2016, expanded coverage to a prospective longitudinal study while keeping CED. Q13. What must a CED study demonstrate? Clinically meaningful improvement in function/quality of life, reduction in pain, and effect on overall clinical management, each versus other treatments. Q14. Does commercial insurance cover PILD?
Coverage is fragmented; many national plans classify image-guided PILD/MILD as
experimental/investigational, while a minority cover under narrow criteria. Q15. Does the CED framework apply to commercial plans? No. CED is a Medicare construct. A commercial request is an ordinary coverage/medical-necessity question. Q16. How is PILD coverage different from Vertiflex? PILD is CED-only under Medicare; Vertiflex has no NCD or active LCD and is adjudicated on medical necessity to its FDA indication. The two are near-opposites. Q17. What is the primary diagnosis code? M48.062 (lumbar spinal stenosis with neurogenic claudication). M48.06 is a non-billable parent and will be rejected. Q18. Where is PILD performed? Hospital outpatient (POS 22, TOB 13X/85X) or ambulatory surgery center (POS 24). Q19. Is there an implant or MRI-conditionality concern? No. PILD places no implant, so there is no device HCPCS and no MRI-conditionality consideration for the therapeutic procedure.
Q20. Should a Medicare PILD service billed outside CED be appealed? No. The remedy is to correct the CED conditions or confirm study participation — not to appeal a non-covered service into coverage. Q21. What is the strongest single Medicare control? Verifying site study participation and capturing the 8-digit trial identifier at intake, with a hard stop on scheduling without it. Q22. Where can the clinical and device detail be found? In the MILD guide (Guide 01), which carries the fuller clinical, device, and general-coding discussion for the same procedure.
27. Key Takeaways
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- PILD is the CMS coverage term for the procedure marketed as MILD — same procedure, same codes.
- Medicare covers PILD only under CED (NCD 150.13); outside an approved study it is non-covered.
- A payable CED claim carries Z00.6 + Condition Code 30 + an 8-digit trial identifier from a
participating site.
- Billing PILD outside CED is a compliance exposure, not just a denial — gate scheduling on
enrollment.
- 2026 coding: 62330 / +62331 replaced deleted 0275T; 62380 (endoscopic) is a miscoding trap;
G0276 is the blinded-arm code.
- Commercial coverage is fragmented and often investigational; that is a separate problem from the
Medicare CED gate.
28. Future Outlook
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The pivotal variable for PILD is whether and when CMS reconsiders NCD 150.13 and removes the CED requirement. A CED cycle ends only when CMS completes a reconsideration and lifts study participation as a condition of coverage; until that happens, the operational rules in this guide stand. Accumulating longer-term and comparative evidence — including multi-year MOTION results — is the lever most likely to prompt reconsideration, and CMS refreshed its general CED guidance in 2024. Practices should watch the CMS coverage database for any PILD reconsideration and re-verify commercial policies each cycle. Regardless of how coverage evolves, the discipline — gate Medicare on CED, treat commercial as a medical-necessity question, and never conflate the two — remains the right operational posture.
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-00433N (initial NCD, 2014) and CAG-00433R
(reconsideration, 2016). https://www.cms.gov/medicare-coverage-database
- Centers for Medicare & Medicaid Services. Coverage with Evidence Development (updated guidance, August 7,
2024). https://www.cms.gov/medicare/coverage/evidence
- American Medical Association. CPT® 2026 code set (62330, +62331; deletion of 0275T).
https://www.ama-assn.org/practice-management/cpt
- HCPCS G0276 — blinded/placebo-controlled PILD CED trial procedure (valid 2026).
https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system
- 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/
- ICD-10-CM 2026: M48.061 / M48.062 (lumbar spinal stenosis); Z00.6 (clinical research encounter).
https://www.cms.gov/medicare/coding-billing/icd-10-codes
- GoHealthcare MSK Specialty Procedure Library — Guide 01: MILD (clinical, device, and general coding detail).
30. Reading Recommendations
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- CMS NCD 150.13 and the CAG-00433N/CAG-00433R decision memos — the authoritative Medicare
coverage framework.
- CMS Coverage with Evidence Development guidance (2024) and the approved-study listing for NCD
150.13.
- MiDAS ENCORE and MOTION trials — the core comparative evidence cited in commercial appeals.
- The GoHealthcare MILD guide (Guide 01) for clinical, device, and general coding detail.
31. Related GoHealthcare Resources (Internal Links)
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- GoHealthcare MSK Specialty Procedure Library — Guide 01: MILD (the clinical/device companion to
this page).
- GoHealthcare MSK Specialty Procedure Library — Guide 02: Vertiflex / Superion (coverage contrast).
- GoHealthcare Compliance Knowledge Center — Coverage with Evidence Development and
clinical-trial billing.
- GoHealthcare Revenue Cycle Knowledge Center — condition codes and clinical-trial claim
mechanics.
32. Recommended Downloads
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- PILD CED claim checklist (Z00.6 + Condition Code 30 + 8-digit trial identifier).
- Medicare PILD intake gate: study-enrollment verification form.
- 2026 coding quick-card (62330 / +62331; G0276 blinded arm; M48.062).
- Commercial appeal template for image-guided decompression with randomized-evidence citations.
33. Visual Recommendations
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- Decision tree: Medicare PILD — is the site in an approved CED study? If not, do not schedule.
- CED claim-conditions checklist graphic (Z00.6, Condition Code 30, trial identifier).
- Coverage timeline: 2014 initial NCD → 2016 reconsideration → current CED status.
- Benefit-type branching flowchart (Medicare CED gate vs. commercial medical-necessity pathway).
- Coding comparison: 62330/+62331 vs. deleted 0275T vs. endoscopic 62380.
34. Document History
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Version Date Summary
1.0 2026 Initial publication under GoHealthcare Clinical Procedure Guide Standard v1.0.
Coverage-lens companion to the MILD guide; reflects NCD 150.13 CED framework, CED claim conditions (Z00.6, Condition Code 30, 8-digit trial identifier), the 2026 CPT® transition (62330/+62331), and the 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, including MILD®, 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)