CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

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

Commercial product medical coverage policy for interspinous and interlaminar stabilization/distraction devices (spacers) for treatment of lumbar spinal stenosis and related indications; defines medical necessity determinations, exclusions, coding, and references. Not applicable to Medicare Advantage (see related policies).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

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

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2023

Next Review Date

Key ActionReview device removal for medical necessity per the related 'Removal of Implantable Devices' policy and report an appropriate unlisted CPT code for removal procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

CommercialPayer applicability

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Coverage Summary

Policy scope: Commercial products only; not applicable to Medicare Advantage (see related policies). Effective date: 02/01/2023; Last review: 05/07/2025. Headline stance: Interspinous and interlaminar spacers are not medically necessary when used as stand-alone spacers for lumbar spinal stenosis and neurogenic claudication, and interlaminar stabilization following decompression surgery is also considered not medically necessary. Removal of devices for medical reasons (device failure, infection, etc.) requires individual review for medical necessity and there is no specific CPT code for removal (report appropriate unlisted CPT).

Key policy values

Payer applicabilityCommercial only

Stand-alone spacers stanceNot medically necessary

Interlaminar after decompression stanceNot medically necessary

Device removal stanceReview required for medical reasons; no specific CPT — use appropriate unlisted CPT

Effective date02/01/2023

Last review date05/07/2025

Medical Necessity Determinations

Covered / Not Medically Necessary Determinations

Policy statements for Commercial Products:

Stand-alone procedure: Interspinous or interlaminar distraction devices as a stand-alone procedure are not medically necessary as a treatment of spinal stenosis as the evidence is insufficient to determine the effects of the technology on health outcomes.
Post-decompression stabilization: Use of an interlaminar stabilization device following decompression surgery is not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.
Replacement device: Insertion of a replacement device after removal is not medically necessary.

CPT / HCPCS Coding

Not Medically Necessary (Commercial Products)CPTNot 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).

Not Medically Necessary (Commercial Products) - HCPCS / ImplantHCPCSNot Covered

C1821

Interspinous distraction device (implantable) process

Removal of deviceCPT

UNLISTED

No specific CPT code for removal of interlaminar/interspinous process stabilization/distraction devices; appropriate unlisted CPT code should be used.

Provider Actions & Billing Rules

Documentation Required

Review device removal for medical necessity

Removal for medical reasons (device failure, infection, etc.) must be reviewed for medical necessity per related policy 'Removal of Implantable Devices'.

Removal of Implantable Devices

Billing Rule

Use unlisted CPT for device removal

Because there is no specific CPT code for removal of interlaminar/interspinous spacers, report an appropriate unlisted CPT code for removal procedures.

There is no specific CPT for removal of these devices — report an appropriate unlisted CPT code.

Background & Evidence Summary

Interspinous and interlaminar spacers are implants placed between spinous processes or between adjacent lamina and spinous processes to distract the neural foramina, restrict extension, and provide dynamic stabilization for patients with lumbar spinal stenosis and neurogenic claudication. The evidence base includes randomized controlled trials, systematic reviews, and observational/claims studies. Overall study results are mixed: some trials (for example the Superion pivotal trial) reported improvements in some quality-of-life domains, but other trials (for example the coflex/FELIX trials) demonstrated substantially higher reoperation rates with implants compared with decompression. Systematic reviews and comparative analyses have shown increased reoperation rates and no consistent, significant improvements in pain, function, or quality-of-life outcomes. Consequently, the evidence is considered insufficient to demonstrate a net health benefit for routine use of these devices.

Key Evidence

Definitions

Interspinous spacerSmall device implanted between vertebral spinous processes to distract neural foramina and restrict extension.

Interlaminar spacerImplant placed between adjacent lamina and spinous processes to provide dynamic stabilization, typically after decompression or as an alternative to decompression.

OpenPayer

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

Coverage Summary

Medical Necessity Determinations

CPT / HCPCS Coding

Provider Actions & Billing Rules

Background & Evidence Summary

Revision History

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

Coverage Summary

Medical Necessity Determinations

CPT / HCPCS Coding

Provider Actions & Billing Rules

Background & Evidence Summary

Scope and Related Policies

Revision History