China’s total coal production in 2021 exceeded 4.13 billion tons, 52% of the world’s total. Coal gangue, a solid waste of coal mining accounts for 15–20% of coal production, when directly discharged on the ground surface as waste heaps, it occupies large areas of land and cause environmental pollution. This paper summarizes the existing gangue backfilling methods, their working principles, efficiency, and application status. The methods that are meeting Middle and Western China’s mining demands are discussed in detail. The state-of-the-art technologies that can realize high-efficiency, centralized, and large-scale underground backfilling of coal gangue are analyzed. This paper shows that the industrial implementation of these technologies can increase the current maximum disposal capacity of coal gangue by three times, reaching five million tons per year. The equipment innovation and automation are analyzed, and the environmental effect of coal gangue backfilling is discussed. This review offers inspirations and guidelines for coal gangue disposal and the environmental hazard reduction of coal mining.