Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
This policy governs coverage and medical necessity determinations for interspinous and interlaminar spinal spacer implants used to treat lumbar spinal stenosis and related indications for Blue Cross Blue Shield - Rhode Island members. It addresses stand-alone spacer use, spacers used after decompression, and device removal/replacement coverage.
No material clinical or coverage changes in this revision.
Coverage Determinations and Criteria
Coverage determinations and evidence conclusions
Policy coverage stance and summarized evidence conclusions
Evidence-based coverage rationale
Summary of evidence and coverage stance from this document:
See full references in document.
Removal of interspinous or interlaminar spacer devices for medical reasons (for example, device failure or infection) is covered for all members. However, insertion of a replacement device after removal is not covered for Medicare Advantage Plans and is not medically necessary for Commercial Products.
The following insertion and implant codes are identified by this policy as not covered for Medicare Advantage Plans and not medically necessary for Commercial Products: CPT 22867, 22868, 22869, 22870, and HCPCS C1821.
Interspinous or interlaminar distraction devices used as a stand-alone procedure for treatment of lumbar spinal stenosis are considered not medically necessary for Commercial Products and not covered for Medicare Advantage Plans because the evidence is insufficient to determine effects on health outcomes.
Placement of interlaminar/interspinous stabilization or distraction devices when billed with CPT codes 22867–22870 or HCPCS C1821 is considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products under this policy.
Billing Codes and Status
| 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 CPT | Appropriate Unlisted CPT code should be used for removal of interlaminar/interspinous process stabilization/distraction devices (no specific CPT exists) |
Provider Requirements, Prior Authorization, and Documentation
Prior Authorization
Prior authorization is not applicable for Medicare Advantage Plans and Commercial Products.
- Medicare Advantage Plans: Not applicable
- Commercial Products: Not applicable
Coverage Status and Prior Authorization
Interspinous/interlaminar device insertions and implants listed below are not covered for Medicare Advantage Plans and are not medically necessary for Commercial Products. Removal of devices for medical reasons (device failure, infection, etc.) is covered for all members; insertion of a replacement device after removal is not covered/not medically necessary. Providers should verify member eligibility and benefits before billing.
- Stand‑alone interspinous or interlaminar distraction devices as a treatment of spinal stenosis — not covered / not medically necessary
- Use of an interlaminar stabilization device following decompression surgery — not covered / not medically necessary
- Removal for medical reasons — covered for all members; insertion of a replacement device after removal — not covered / not medically necessary
Not Covered Insertion and Implant Codes
The following insertion and implant codes are identified as not covered for Medicare Advantage Plans and not medically necessary for Commercial Products. Use an appropriate Unlisted CPT code for device removal when no specific CPT exists. Verify member benefits and eligibility prior to service.
- CPT 22867 — Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, with open decompression, single level — not covered / not medically necessary
- CPT 22868 — Insertion, second level (add-on) — not covered / not medically necessary
- CPT 22869 — Insertion without open decompression or fusion, single level — not covered / not medically necessary
- CPT 22870 — Insertion without open decompression or fusion, second level (add-on) — not covered / not medically necessary
- HCPCS C1821 — Interspinous process distraction device (implantable) — not covered / not medically necessary
- Removal: No specific CPT exists — use appropriate Unlisted CPT code
Required Clinical Documentation (per device indications)
Device-specific indications require imaging and clinical confirmation per manufacturer labeling. For interlaminar spacers (e.g., Superion®) and interlaminar stabilization devices (e.g., coflex®), confirm diagnosis with x‑ray, MRI, and/or CT evidence of ligamentum flavum thickening, lateral recess and/or central canal or foraminal narrowing, and documentation of symptom relief with flexion. Also document at least 6 months of nonoperative/conservative treatment prior to implantation. Maintain imaging reports, clinical notes describing functional impairment, symptom pattern (relief in flexion), and documentation of prior conservative therapies.
- Confirmatory imaging: x‑ray, MRI, and/or CT showing relevant anatomic findings
- Clinical documentation: symptoms (leg/buttock/groin pain, numbness/cramping), functional impairment, and relief with flexion
- Conservative therapy: record ≥6 months of nonoperative treatment and modalities attempted (e.g., physical therapy, pharmacotherapy, epidural steroid injections)
- For coflex® when used after decompression, document decompression surgery and rationale for stabilization
Coding and Member Eligibility
Billing and coding guidance: verify member benefits and use appropriate codes. Removal for medical reasons is covered; when no specific CPT exists for removal, report an appropriate Unlisted CPT. Providers should confirm eligibility and benefit coverage prior to performing or billing for procedures.
- Verify member eligibility and subscriber agreement or certificate prior to service
- Use appropriate Unlisted CPT for device removal (no specific CPT available)
- Do not bill for insertion of replacement devices for members — insertion is not covered/not medically necessary
Provider and Billing Notice
This policy is informational and not a guarantee of payment. Benefits and eligibility are determined by the member's subscriber agreement or member certificate; contact the provider call center for member‑specific benefits. Providers may not bill members for noncovered or medically unnecessary services unless the member was informed and agreed in writing in advance.
- Contact provider call center for member‑specific benefits and eligibility
- Provider charge to member for noncovered services allowed only with prior written member agreement
Device and Term Definitions
Clinical Background
Lumbar spinal stenosis (LSS) is a degenerative narrowing of the spinal canal, lateral recesses, or neural foramina that can produce neurogenic claudication and functional impairment, most commonly in older adults. Management begins with conservative therapies — including physical therapy, medications, and epidural steroid injections — and progresses to surgical options for patients who fail nonsurgical care or have progressive neurologic deficits. Interspinous and interlaminar spacer implants are minimally invasive devices intended to distract or stabilize the posterior elements, restrict extension, and enlarge neural foramina to relieve symptoms; however, randomized trials and device data have produced mixed results with concerns about reoperation and device-related complications, which is why the policy restricts stand-alone use and certain billed insertions.
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