CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

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

Coverage policy for use of interspinous and interlaminar spinal spacer devices for lumbar spinal stenosis for Commercial Products of Blue Cross Blue Shield - Rhode Island; describes clinical evidence and coverage stance for stand-alone and adjunctive use. Applies to commercial members; Medicare Advantage referred to related policies.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyInterspinous and Interlaminar Stabilization/Distraction Devices (Spacers) Coverage Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date02/01/2023

Next Review DateN/A

Key ActionCheck contract-specific coverage and prior authorization requirements in the member's Benefit Booklet or Evidence of Coverage before proceeding.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

200,000+people in US affected

6 monthsmin nonoperative treatment

29%reoperation rate (pivotal)

14%reoperation rate (fusion conv.)

Multiple

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Listedcodes not medically necessary

Coverage Determinations and Evidence

Coverage determinations and evidence-based criteria

Policy coverage stance and evidence summary

Stand-alone spacer: Interspinous or interlaminar distraction devices used as a stand-alone procedure for spinal stenosis are not medically necessary due to insufficient evidence of net health benefit.

Supported by randomized controlled trials showing high failure and complication rates and limitations in comparators that limit interpretation.

Interlaminar spacer after decompression: Use of an interlaminar stabilization device following decompression surgery is considered not medically necessary because evidence is insufficient to determine effects on health outcomes.

RCTs provide mixed or noninferior results but interpretation is limited by uncertainty about the benefit of the comparator (fusion) and higher reoperation rates in some trials.

Device-specific indications: Certain devices (e.g., Superion, coflex) have manufacturer indications (skeletally mature patients with imaging-confirmed moderate degenerative lumbar stenosis and symptom relief with flexion) and typically require at least 6 months of nonoperative care, but the overall evidence remains insufficient to support routine coverage of spacers as alternatives to decompression or as adjuncts in many settings.6 months nonoperative care

Manufacturer indications are summarized in trials but do not change the policy's overall insufficient evidence stance.

Insufficient evidence / Not proven to improve net health outcome

Coverage stance and evidence summary

Evidence and interpretation: The evidence from randomized controlled trials, including a pivotal noninferiority trial of coflex plus decompression versus decompression plus fusion, is insufficient to demonstrate improvement in net health outcome for interlaminar spacers. Interpretability is limited because the comparator (decompression plus fusion) has uncertain net benefit in the studied population and outcomes comparing devices plus decompression to decompression alone in patients without spondylolisthesis have not been reported.

Results are confounded by uncertainty about the benefit of fusion in the trial population and by higher reoperation rates observed with some devices.

Interspinous or interlaminar distraction devices when used as a stand-alone procedure for treatment of lumbar spinal stenosis are not medically necessary. This determination reflects the policy conclusion that current evidence is insufficient to demonstrate a net health benefit for standalone spacer implantation. Benefits and coverage may vary by contract; providers should refer to the member’s Benefit Booklet or Evidence of Coverage for applicable coverage rules.

Available randomized trial data and subgroup information do not report outcomes for patients without spondylolisthesis who received an interlaminar device with decompression. Because these outcomes have not been reported, applicability of the trial results to this subgroup is limited and the evidence is insufficient to conclude improvement in net health outcome.

Use of an interlaminar stabilization device following decompression surgery is considered not medically necessary because the evidence does not adequately demonstrate improved health outcomes when these devices are used as an adjunct to decompression. The policy therefore excludes both stand‑alone spacer procedures and the use of interlaminar stabilization devices after decompression from routine coverage in the absence of stronger evidence. As with other exclusions, benefits may vary by contract and providers should verify coverage in the applicable benefit documents.

Specific procedure and implant billing codes for interlaminar/interspinous stabilization or distraction devices are designated not medically necessary. The following codes are listed as not medically necessary for Commercial Products: 22867, 22868, 22869, 22870, and C1821. For removal of these devices there is no specific CPT code; an appropriate Unlisted CPT code should be used.

Billing and Coding

Commercial Products - Not medically necessarymixedNot 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).
C1821	Interspinous process distraction device (implantable)

Removal codingCPT

Unlisted CPT

Appropriate unlisted CPT code should be used for removal of interlaminar/interspinous process stabilization/distraction devices (no specific CPT exists).

Provider Requirements and Operational Guidance

Prior Authorization

Check contract benefits and prior authorization

Check contract-specific coverage and prior authorization requirements in the member's Benefit Booklet / Evidence of Coverage; benefits and coverage for interspinous/interlaminar devices may vary by group or contract.

Refer to member Benefit Booklet / Evidence of Coverage for applicable coverage and prior authorization requirements.

Prior Authorization

Prior authorization guidance

Prior authorization may be required for spinal procedures. See the payer's related policy on Prior Authorization of Spinal Procedures for guidance before scheduling or performing interspinous or interlaminar device implantation or related spinal surgeries.

Prior Authorization of Spinal Procedures (related policy).

Clinical Background

Lumbar spinal stenosis (LSS) is a degenerative narrowing of the spinal canal, lateral recesses, or neural foramina that can compress neural elements and produce neurogenic claudication and functional limitation. Many patients are managed conservatively, while those with more severe disease, deformity, or neurologic compromise may require surgical decompression with or without fusion. Clinical trials comparing operative and nonoperative strategies show mixed results, and the role of less invasive spacer devices as alternatives to or adjuncts with decompression remains uncertain.

Device Definitions

Interspinous spacer — definition and implantation summary

DefinitionSmall device implanted between the vertebral spinous processes that is opened or expanded after implantation to distract the neural foramina, decompress nerve roots, and restrict spinal extension.

Implantation approachInserted between spinous processes through a small (4–8 cm) incision in some devices; supraspinous ligament may be preserved to help retain the implant.

Surgical scopeMay be placed without laminectomy/foraminotomy for some devices, reducing risk of epidural scarring and CSF leak; other designs require removal of the interspinous ligament and fixation around spinous processes.

Intended physiologic effectDistracts the laminar space and/or spinous processes to maintain flexion at the treated interspace and enlarge neural foramina to relieve neurogenic claudication.

Interlaminar spacer — definition and typical use (U-shaped implant, dynamic stabilization)

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyInterspinous and Interlaminar Stabilization/Distraction Devices (Spacers) Coverage Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date02/01/2023

Next Review DateN/A

Key ActionCheck contract-specific coverage and prior authorization requirements in the member's Benefit Booklet or Evidence of Coverage before proceeding.

SourceLink

On This Page

Documentation Required

Conservative management required before surgery

Conservative (nonoperative) management is recommended and generally required to be attempted and documented prior to considering surgical options such as interspinous or interlaminar spacer implantation.

Conservative treatments may include physical therapy, pharmacotherapy, epidural steroid injections, and other nonsurgical modalities.
Professional-society guidance and device labeling reference at least 6 months of nonoperative treatment prior to implantation for indicated devices.

Documentation Required

Required clinical documentation for indicated devices

Providers must submit imaging-confirmed documentation of moderate degenerative lumbar stenosis when billing for indicated devices and include device-specific clinical documentation (e.g., evidence of symptom relief in flexion, prior nonoperative treatment duration, level(s) treated).

MRI or CT evidence of ligamentum flavum thickening, lateral recess or central canal/foraminal narrowing as applicable.
Documentation that the patient had at least 6 months of nonoperative treatment when device indications specify this requirement.

Denial Risk

Denial triggers for stand-alone and adjunctive spacer use

Stand-alone interspinous or interlaminar distraction devices and interlaminar stabilization following decompression surgery are listed as not medically necessary for treatment of spinal stenosis; billing for these uses may trigger denial.

Stand-alone use of interspinous/interlaminar devices for spinal stenosis — Not medically necessary.
Use of interlaminar stabilization device following decompression surgery — Not medically necessary.

Billing Rule

Not medically necessary coding and device removal coding

Use the listed CPT and HCPCS codes designated as not medically necessary when applicable; when removing interlaminar/interspinous devices there is no specific CPT code — use an appropriate Unlisted CPT code for device removal.

Not medically necessary codes: 22867, 22868, 22869, 22870, C1821.
There is no specific CPT code for device removal — submit an appropriate Unlisted CPT code for removal procedures.

Note

PROVIDER ACTIONS

When prior authorization or medical review is required, include all relevant clinical documentation (history of conservative management, imaging, symptom description, device-specific indications) to support medical necessity and avoid delays or denials.

Include duration and components of conservative treatment attempted (e.g., PT, injections).
Provide imaging reports confirming level and degree of stenosis and any spondylolisthesis or deformity status.

DefinitionU-shaped implant placed midline between adjacent lamina and spinous processes to provide dynamic stabilization by distracting the laminar space and restricting extension.

Typical designSingle-piece U-shaped titanium dynamic stabilization device (example: coflex) that surrounds superior and inferior spinous processes.

Typical useUsed either following decompression surgery as interlaminar stabilization or as an alternative to decompression; intended to enable restriction of motion while allowing normal motion.

Indication contextOften indicated for skeletally mature patients with moderate functional impairment and symptom relief in flexion after at least 6 months of nonoperative treatment (manufacturer indications).

Interlaminar/interspinous spacer — combined definition for spacer devices used with or without decompression

Combined definitionAn implantable spacer placed between the spinous processes or midline between laminae to provide stabilization/distraction and restrict extension; may be used with or without open decompression for lumbar spinal stenosis.

Use with decompressionInterlaminar spacers are frequently implanted after decompression surgery as a form of stabilization; pivotal trials have compared interlaminar spacer plus decompression with decompression plus fusion.

Use without decompressionInterspinous spacer designs can be inserted without laminectomy/foraminotomy to act as a stand‑alone spacer that maintains flexion at the treated level.

Evidence noteEvidence is insufficient to show improvement in net health outcome for spacers used as stand‑alone procedures or when used adjunctively because trial comparators and subgroup reporting limit interpretability.