CurrentevicorePolicy CMM-608

Lumbar Decompression, Corpectomy, and Related Device Use

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Clinical coverage criteria for lumbar decompression procedures, repeat decompression, corpectomy, and use of interlaminar/interspinous devices for providers submitting authorization requests to evicore.

Policy Summary

Payerevicore

PolicyLumbar Decompression, Corpectomy, and Related Device Use

Policy CodePolicy CMM-608

Change TypeNo material change

Effective DateAug 4, 2026

Next Review Date

Key ActionRequest prior authorization with documentation of symptoms, concordant exam and imaging, and required prior conservative therapy (unless urgent/emergent).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentevicorePolicy CMM-608

Lumbar Decompression, Corpectomy, and Related Device Use

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Sign up for evicore Policy CMM-608 alerts

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Policy Summary

Payerevicore

PolicyLumbar Decompression, Corpectomy, and Related Device Use

Policy CodePolicy CMM-608

Change TypeNo material change

Effective DateAug 4, 2026

Next Review Date

Key ActionRequest prior authorization with documentation of symptoms, concordant exam and imaging, and required prior conservative therapy (unless urgent/emergent).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Fusion requiredCorpectomy requirement

>=12 wksMin interval for repeat surgery

≥2 therapiesConservative therapy prior to repeat

1-2 levelsCoflex level limits

Certain IPD/MILDExperimental/Investigational

57Reference citations

Coverage Criteria for Lumbar Procedures

Corpectomy coverage

Lumbar corpectomy is considered medically necessary when ALL of the following are met:

Corpectomy indications: Complete or partial corpectomy (removal of at least one‑third of the vertebral body; not for resection of osteophytes alone) is performed for infection, trauma, tumor, or compression at or behind the level of the vertebral body.

Fusion requirement: Lumbar corpectomy is performed with a lumbar fusion due to the iatrogenic instability created by corpectomy.

Applicable decompression criteria: Applicable lumbar decompression criteria (see CMM‑608.2: Initial Primary Lumbar Decompression) have been met for the planned procedure.

Repeat decompression coverage (Neurogenic Claudication or Radiculopathy)

Repeat lumbar decompression at the same level is considered medically necessary when EITHER of the following condition groups are met and ALL associated criteria are satisfied:

Neurogenic Claudication cluster: Greater than 12 weeks since the prior lumbar decompression; symptoms include BOTH a clinically significant level of daily pain/functional impairment and neurogenic symptoms provoked by walking/standing (e.g., pain, cramping, weakness, or tingling) with worsening on standing/walking or relief with sitting/forward flexion; less than clinically meaningful improvement after at least TWO conservative treatments (prescription analgesics/steroids/gabapentinoids/NSAIDs for 6 weeks; provider‑directed exercise program for 6 weeks; and/or epidural steroid injection(s) or selective nerve root block(s) at the same level); post‑operative MRI/CT demonstrates concordant neural compression at the requested level caused by herniated disc (retained or recurrent), synovial/arachnoid cyst, central/lateral/foraminal stenosis, or osteophytes; and absence of unmanaged significant mental/behavioral health disorders.>= 12 weeks since prior decompression

Conservative therapies described in policy (6 weeks each)

Radiculopathy cluster: Greater than 12 weeks since the prior lumbar decompression; symptoms include BOTH a clinically significant level of daily pain/functional impairment and persistent radiating pain to the buttock(s) and/or lower extremity(ies); physical exam demonstrates ANY of: positive straight leg raise, positive crossed straight leg raise, positive femoral stretch test, dermatomal sensory deficit, functionally limiting motor weakness (e.g., foot drop, quadriceps weakness), reflex changes, or unremitting radicular pain without concordant objective findings; less than clinically meaningful improvement after at least TWO conservative treatments (as listed for neurogenic claudication) unless contraindicated; post‑operative MRI/CT demonstrates concordant neural compression at the requested level caused by herniated/recurrent disc, synovial/arachnoid cyst, central/lateral/foraminal stenosis, or osteophytes; and absence of unmanaged significant mental/behavioral health disorders.

Interlaminar decompression device coverage

Use of an FDA‑approved interlaminar decompression device (e.g., Coflex) is considered medically necessary when ALL of the following are met:

Meets repeat decompression criteria: The candidate meets the repeat lumbar decompression criteria for either Neurogenic Claudication or Radiculopathy.

Not used with fusion: The interlaminar decompression device will not be used when the open lumbar decompression is performed with a lumbar fusion at the same level.

Level limitation: The device will be used only at one or two lumbar levels between L1 and L5.1-2 levels between L1-L5

Spondylolisthesis allowance: Meyerding Grade 1 spondylolisthesis is permissible; anticipated iatrogenic instability from extensive facet excision (exceeding 50% bilaterally or >=75% of a single facet) is addressed per policy.

Medical Necessity Criteria

Covered when documentation supports:

Primary coverage criteria: Symptoms, physical examination findings, and imaging are concordant and support lumbar decompression surgery; a trial of non‑operative treatment of approximately six (6) weeks is recommended prior to elective surgery.6 weeks of conservative care

Urgent/emergent conditions (e.g., cauda equina syndrome, infection, epidural hematoma) obviate the conservative care requirement

Procedures such as lumbar decompression, lumbar discectomy, and lumbar corpectomy that are performed without meeting the policy’s General Guidelines (including requirement for a credentialed spine surgeon and documented urgent/emergent indications when applicable) and the applicable procedure‑specific criteria are considered not medically necessary and may be denied.

Use of an interlaminar decompression device (e.g., Coflex) is limited by the policy. Coflex is not medically necessary when used without meeting the decompression criteria in the applicable procedure section, when used in the presence of Meyerding Grade 2 or higher spondylolisthesis, when spondylolysis/isthmic spondylolisthesis is present, when a lumbar fusion is also being performed at the same level, or when decompression is not performed as an open procedure.

For elective lumbar decompression the policy expects documentation of a trial of conservative (non‑operative) care of approximately six weeks prior to surgery. Urgent or emergent conditions (for example, cauda equina syndrome, infection, or epidural hematoma) override this requirement and allow immediate surgical intervention.

Lumbar decompression, discectomy, and corpectomy performed without meeting both the General Guidelines and the applicable procedure‑specific criteria are considered not medically necessary. Requests lacking required credentialing, appropriate indications, or relevant supporting documentation may be denied.

Percutaneous lumbar decompression techniques (for example, MILD®) and interspinous/interlaminar spacer, stabilization/distraction, or IPD systems (for example, Superion®, X‑STOP®, TOPS®) are considered experimental, investigational, or unproven for all indications and may be denied.

Procedures where patient symptoms and physical examination findings are not concordant with imaging, or where there is inadequate documentation of prior conservative care when indicated, are at risk of being considered not medically necessary. The policy requires concordant symptoms, exam, and imaging to support lumbar decompression and documentation of prior non‑operative treatment when applicable.

Procedure and Corpectomy Codes

Listed Procedure CPT CodesCPT

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)
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)
62330	Decompression, percutaneous, with partial removal of the ligamentum flavum, including laminotomy for access, epidurography, and imaging guidance, bilateral; one interspace, lumbar
+62331	Decompression, percutaneous, with partial removal of the ligamentum flavum... additional interspace(s), lumbar (List separately in addition to code for primary procedure)
62380	Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar
63005	Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, 1 or 2 vertebral segments; lumbar
63011	Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, 1 or 2 vertebral segments; sacral
63012	Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)

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Covered CPT CodesCPTCovered

63053	Laminectomy, facetectomy, or foraminotomy ... during posterior interbody arthrodesis, lumbar; each additional segment (List separately)
63087	Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression..., single
+63088	Vertebral corpectomy ... each additional segment (List separately in addition to code for primary)
63090	Vertebral corpectomy ... transperitoneal or retroperitoneal approach ... single segment
+63091	Vertebral corpectomy ... each additional segment (List separately in addition to code)
63102	Vertebral corpectomy ... lateral extracavitary approach ...; lumbar, single segment
+63103	Vertebral corpectomy ... lateral extracavitary approach... each additional segment (List separately)
63267	Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar
63272	Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar
63277	Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar

Authorization, Documentation, and Provider Guidance

Prior Authorization

Codes may require prior authorization

Prior authorization may be required for the listed lumbar decompression and corpectomy CPT codes; inclusion in the code table does not guarantee payment and plan-specific management details apply.

See code list for codes that may require prior authorization; refer to the applicable health plan for management details.

Prior Authorization

Request authorization for listed procedure codes

Providers should request prior authorization for the listed lumbar decompression and corpectomy procedure codes and submit supporting documentation including symptoms, exam, imaging, and prior conservative care as applicable.

Request authorization for covered/decompression and corpectomy CPT codes listed in the policy.
Include clinical documentation that supports medical necessity per the procedure-specific criteria.

Background and Evidence

A corpectomy is the partial or complete removal of a vertebral body (typically defined as removal of at least one‑third of the vertebral body rather than resection of osteophytes alone). It is performed for indications such as infection, trauma, tumor, or retropulsed bone causing compression, and when performed in the lumbar spine it is expected to be accompanied by lumbar fusion due to the instability created by the procedure.

Definitions and Procedure Descriptions

Corpectomy definition — Complete or partial corpectomy defined as removal of at least one-third of vertebral body

DefinitionComplete or partial corpectomy: removal of at least one-third of the vertebral body (not for resection of osteophytes alone).

IndicationsPerformed for infection, trauma, tumor, or compression at or behind the level of the vertebral body.

Procedure requirementLumbar corpectomy must be performed with a lumbar fusion due to the iatrogenic instability of the corpectomy procedure.

Interlaminar decompression device (Coflex) limitations — Use limited to 1-2 lumbar levels L1-L5 and not used when fusion is performed

Level limitationDevice will only be used at one or two lumbar levels between L1-L5.

Fusion restriction

Policy Revision History

Policy Summary

Payerevicore

PolicyLumbar Decompression, Corpectomy, and Related Device Use

Policy CodePolicy CMM-608

Change TypeNo material change

Effective DateAug 4, 2026

Next Review Date

Key ActionRequest prior authorization with documentation of symptoms, concordant exam and imaging, and required prior conservative therapy (unless urgent/emergent).

SourceLink

On This Page

>= 12 weeks since prior decompression

See policy for required documentation elements (prior surgery date, concordant imaging, exam, and conservative care)

Meyerding Grade 1 only

Device not indicated for Grade 2 or higher or in presence of spondylolysis/isthmic spondylolisthesis

Note

Guideline citations (informational)

The policy cites North American Spine Society (NASS) Appropriate Use Criteria and Coverage Policy Recommendations (e.g., Lumbar Decompression, Interspinous Device, Endoscopic Decompression) as supporting guideline materials.

Examples include NASS Appropriate Use Criteria: Degenerative Lumbar Spondylolisthesis and NASS Coverage Policy Recommendations: Lumbar Decompression, Endoscopic Decompression, and Interspinous Device guidance.

Step Therapy

Trial of ≥2 conservative therapies required before repeat decompression

Repeat lumbar decompression requests must document that the individual had less than clinically meaningful improvement after at least two specified conservative treatments (each 6 weeks unless contraindicated) before repeat surgery.

Acceptable conservative treatments include: prescription analgesics/steroids/gabapentinoids/NSAIDs for six weeks; a provider-directed exercise program for six weeks; and/or epidural steroid injections or selective nerve root blocks.

Step Therapy

Expect ~6 weeks of conservative care before elective surgery

A trial of conservative (non-operative) care of approximately six weeks is expected prior to elective lumbar decompression unless an urgent or emergent condition (e.g., cauda equina syndrome, infection, epidural hematoma) is documented.

Most acute back pain and sciatica improve within six weeks with conservative care; document the course unless urgent/emergent.

Step Therapy

No specified step therapy program

No formal step therapy program is specified in this references section.

This section does not establish sequential medication or intervention step requirements beyond the conservative care expectations described elsewhere.

Documentation Required

Documentation required for repeat decompression requests

For repeat decompression requests include documentation of the prior decompression date (greater than 12 weeks prior), a description of current symptoms and functional impairment, objective exam findings, imaging demonstrating concordant neural compression at the requested level, and documentation of required conservative treatments.

Confirm >12 weeks since the prior decompression.
Provide imaging and exam findings that are concordant with symptoms.
Document at least two 6-week conservative treatment attempts unless contraindicated.

Documentation Required

Documentation required for corpectomy requests

For corpectomy requests document the indication (infection, trauma, tumor, or compression at/behind the vertebral body), that the planned resection involves removal of at least one‑third of the vertebral body, and that a lumbar fusion will be performed.

State the corpectomy indication (infection, trauma, tumor, or retropulsed/compressive bone).
Document that ≥1/3 of the vertebral body will be removed (not for osteophyte resection alone).
Document that lumbar fusion will accompany the corpectomy.

Documentation Required

Ensure clinical documentation is concordant with imaging and prior care

Documentation should demonstrate concordant symptoms, physical exam findings, and imaging that support the indication for lumbar decompression and should record prior non‑operative treatment for approximately six weeks unless an urgent/emergent condition is present.

Ensure subjective symptoms and objective exam findings align with imaging evidence of neural compression.
Record the course and duration of prior conservative care or document the urgent/emergent indication if applicable.

Note

NASS guidance cited as supportive material

NASS Appropriate Use Criteria and Coverage Policy Recommendations are cited as source materials that may support documentation and clinical decision-making for lumbar procedures.

Referenced NASS documents include guidance on decompression, interspinous devices, and endoscopic decompression.

Denial Risk

Non‑concordant or non‑criteria procedures may be denied

Procedures that do not meet the General Guidelines and applicable procedure‑specific criteria (initial decompression, repeat decompression, corpectomy) are considered not medically necessary and may be denied.

Ensure all General Guidelines and procedure-specific criteria are met prior to submission to avoid denial.

Denial Risk

Percutaneous and interspinous/interlaminar devices considered E/I/U

Percutaneous lumbar decompression (e.g., MILD) and interspinous/interlaminar spacer or stabilization devices (e.g., Superion, X‑STOP) are considered experimental, investigational, or unproven and may be denied for all indications.

Do not submit requests for these procedures as medically necessary under this policy; they are listed as E/I/U.

Denial Risk

Risk of denial if inadequate conservative care documented

Elective surgery performed without documentation of a recommended course of non‑operative treatment (approximately six weeks) may be at higher risk for denial unless an urgent/emergent condition is documented.

Document the six‑week conservative care course or the urgent/emergent reason to proceed without it to mitigate denial risk.

Note

References are informational only

The References section lists supporting literature and guideline documents and does not itself create additional authorization steps or denial triggers.

Use references to inform clinical justification, but rely on the policy criteria for authorization and denial decisions.

Interlaminar decompression device will not be used for an open lumbar decompression performed with a lumbar fusion.

Candidate requirementUse is limited to patients who meet repeat lumbar decompression criteria for either Neurogenic Claudication or Radiculopathy.

Spondylolisthesis allowanceMeyerding Grade 1 spondylolisthesis is permissible (with or without anticipated iatrogenic instability as defined).

Vertebral corpectomy / Decompression codes — Specific CPT codes describe corpectomy via various approaches

Primary corpectomy codes63087, 63090, 63102 — vertebral corpectomy (partial or complete) via combined thoracolumbar, transperitoneal/retroperitoneal, or lateral extracavitary approaches (single segment).

Add-on corpectomy codes+63088, +63091, +63103 — each additional vertebral segment (List separately in addition to primary code).

Related decompression codes63053, 63267, 63272, 63277 — additional-segment posterior interbody arthrodesis decompression and laminectomy codes for intraspinal lesion procedures.

Lumbar decompression procedures — Includes laminectomy, facetectomy, foraminotomy with decompression of neural elements

Procedure types includedLaminectomy, facetectomy, or foraminotomy (unilateral or bilateral) performed with decompression of the spinal cord, cauda equina, and/or nerve root(s).

Contextual useThese decompression procedures may be performed during posterior interbody arthrodesis (additional-segment coding applies, e.g., 63053).

Example indicationsUsed for spinal or lateral recess stenosis and for tumor or retropulsed bone fragments causing neural compression.