CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)

Defines medical coverage position for interspinous and interlaminar spinal spacers (interspinous/interlaminar stabilization/distraction devices) for lumbar spinal stenosis and neurogenic claudication for BlueCHiP for Medicare and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)

Policy CodePolicy N/A

Change TypeClarified coverage for removal and replacement

Effective DateMar 1, 2018

Next Review Date

Key ActionFor Commercial members, document the reason for removal and do not bill for insertion of a replacement device because replacement insertion is considered not medically necessary and not covered.

SourceLink

POLICY UPDATE CHANGES

Policy states interspinous and interlaminar spacers are considered not medically necessary due to insufficient evidence.

4CPT codes listed as not medically necessary

1Covered action: device removal

Coverage Summary

Scope: Defines medical coverage position for interspinous and interlaminar spinal spacers (interspinous/interlaminar stabilization/distraction devices) for lumbar spinal stenosis and neurogenic claudication for BlueCHiP for Medicare and Commercial products.

Background headline summary: Interspinous and interlaminar spacers are implanted between spinous processes or lamina to restrict extension and distract the neural foramen to decompress nerves in lumbar spinal stenosis and neurogenic claudication; the policy cites randomized trials and systematic reviews (e.g., X-STOP studies) in support of the evidence assessment of insufficiency.

Key items

Subject (policy title)Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)

PayerBlueCHiP for Medicare and Commercial Products

Scope summaryDefines medical coverage position for interspinous and interlaminar spinal spacers for lumbar spinal stenosis and neurogenic claudication for BlueCHiP for Medicare and Commercial products.

Coverage stanceNot medically necessary (not_covered_cosmetic): Interspinous distraction devices and interlaminar stabilization device following decompressive surgery are considered not medically necessary due to insufficient evidence to determine effects on health outcomes.

Effective date2018-03-01

Last review2017-11-21

StatusCURRENT

CPT codes not medically necessary (count)4

Covered action: device removal (count)1

Medical Necessity Criteria

Policy Statement - Medical Necessity

Interspinous distraction devices as a treatment of neurogenic intermittent claudication and interlaminar stabilization device following decompressive surgery:

Interspinous distraction devices as a treatment of neurogenic intermittent claudication are considered not medically necessary because evidence is insufficient to determine the effects of the technology on health outcomes
Interlaminar stabilization device use following decompressive surgery is considered not medically necessary because evidence is insufficient to determine the effects of the technology on health outcomes

Device Removal and Replacement (BlueCHiP for Medicare and Commercial Products)

Coverage rules regarding removal and replacement:

Removal of device for medical reasons (device failure; infection; etc.) is covered for all members
Insertion of a replacement device after removal is not covered for Commercial members (considered not medically necessary)

Coding

CPT codes considered not medically necessaryCPTNot Covered

22867	Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level
22868	Insertion of interlaminar/interspinous process stabilization/distraction device; without fusion; including image guidance when performed, with open decompression, lumbar; second level (list separately in addition to code for primary procedure)
22869	Insertion of interlaminar/interspinous process stabilization/distraction device; without open decompression or fusion, including image guidance when performed, lumbar; single level
22870	Insertion of interlaminar/interspinous process stabilization/distraction device; without open decompression or fusion, including image guidance when performed, lumbar; second level (list separately in addition to code for primary procedure)

Provider Actions

Documentation Required

Do not bill insertion for Commercial members

Insertion of a replacement interspinous or interlaminar device after removal is considered not medically necessary for Commercial members. Do not bill for insertion of a replacement device for Commercial members. Document the reason for removal and note that replacement insertion is noncovered if performed.

22867
22868
22869
22870

Billing Rule

Removal is covered

Removal of interspinous or interlaminar devices for medical reasons (for example, device failure, infection, or other medical complications) is a covered service for all members. Bill the appropriate removal procedure codes and document the medical reason for removal in the medical record.

Document device failure, infection, or other medical reason for removal

Background & Evidence Summary

Interspinous spacers are small devices implanted between adjacent vertebral spinous processes that act as a spacer to maintain flexion at the affected spinal level; some are expanded after implantation to distract (open) the neural foramen and decompress nerves. Interlaminar spacers are implanted midline between adjacent lamina and spinous processes to provide dynamic stabilization either following decompressive surgery or as an alternative to decompressive surgery.

These devices aim to restrict extension while allowing other motion, distract the laminar space and/or spinous processes, and thereby theoretically enlarge the neural foramen to decompress the cauda equina in patients with spinal stenosis and neurogenic claudication.

Policy conclusion: The evidence is insufficient to determine the effects of interspinous or interlaminar spacers on health outcomes when used as a stand-alone procedure for stenosis or when interlaminar spacers are used following decompressive surgery; therefore these uses are considered not medically necessary.

Additional coverage note: Removal of devices for medical reasons (device failure, infection, etc.) is covered for all members, but insertion of a replacement device after removal is not covered for Commercial members (considered not medically necessary).

Evidence cited

Systematic reviews / randomized trials citedMultiple citations including meta-analyses and randomized trials (e.g., X-STOP studies) are referenced as supporting the evidence assessment of insufficiency.