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Commercial-product medical coverage policy for use of interspinous and interlaminar implants (spacers) in lumbar spinal stenosis, including stand-alone use and use following decompression surgery; excludes Medicare Advantage guidance. Defines medical necessity position and coding for Commercial Products.
No material clinical/coverage changes
Commercial-product medical coverage policy for use of interspinous and interlaminar implants (spacers) in lumbar spinal stenosis, including stand-alone use and use following decompression surgery. Coverage stance: Not medically necessary (Commercial) for specified uses of interspinous/interlaminar stabilization/distraction devices. Policy effective date: 02/01/2023; policy last reviewed: 07/03/2024.
Commercial Products - Coverage Determinations
Coverage position for interspinous and interlaminar distraction/stabilization devices for lumbar spinal stenosis:
ALL of the following
This policy applies to Commercial Products only and does not provide Medicare Advantage guidance. It defines medical necessity positions and coding for commercial plans and directs readers to member-specific benefit documents for coverage determinations.
Coverage position: Not medically necessary for commercial products. Specific positions: (1) Interspinous or interlaminar distraction devices as a stand-alone procedure are not medically necessary for treatment of spinal stenosis; (2) Use of an interlaminar stabilization device following decompression surgery is not medically necessary; (3) Insertion of a replacement device after removal is not medically necessary.
| 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). |
| C1821 | Interspinous process distraction device (implantable) |
| UNLISTED | No specific CPT code for removal of interlaminar/interspinous process stabilization/distraction devices; an appropriate Unlisted CPT code should be used. |
Benefit / Contract Verification
Verify member-specific benefits and coverage prior to providing services. Benefits may vary between groups and contracts; refer to the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for member-specific coverage determinations.
Use of Unlisted CPT for Device Removal
There is no specific CPT code for removal of interlaminar/interspinous process stabilization/distraction devices. Report removal using an appropriate unlisted CPT code (UNLISTED).
Interspinous and interlaminar spacers are implants intended to stabilize or distract adjacent lamina and/or spinous processes to restrict extension and relieve neurogenic claudication from lumbar spinal stenosis. The evidence base includes randomized controlled trials, systematic reviews, and observational studies. Overall, trials and reviews have reported higher reoperation and complication rates with spacers compared with decompression (and in some comparisons versus fusion), and the evidence is insufficient to demonstrate a consistent net health benefit of these devices versus decompression or fusion in many settings.
| Evidence | Summary |
|---|---|
| RCTs/Systematic reviews | |
| Evidence shows increased reoperation rates with interspinous/interlaminar devices versus decompression and insufficient evidence of net health benefit | |
| Superion indication | |
| Superion indicated for skeletally mature patients with moderate degenerative lumbar spinal stenosis after at least 6 months of nonoperative treatment (manufacturer labeling) |
Glossary: Interspinous spacers (ISD) — Small devices implanted between vertebral spinous processes that are expanded or distracted to enlarge the neural foramina and decompress nerves; may be inserted via a small incision without bony decompression. Interlaminar spacers — U-shaped implants placed midline between adjacent lamina and spinous processes to provide dynamic stabilization, often implanted following decompression surgery.