ModifiedUnitedHealthcarePolicy CS363NM.C

Interspinous Fusion and Decompression Devices (for New Mexico Only)

Policy governs medical necessity and coverage for interspinous fixation (fusion) devices and interspinous decompression/interlaminar stabilization devices for lumbar spine conditions in New Mexico; affects providers requesting coverage for these devices and related procedures.

Policy Summary

PayerUnitedHealthcare

PolicyInterspinous Fusion and Decompression Devices (for New Mexico Only)

Policy CodePolicy CS363NM.C

Change TypeClinical evidence and documentation guidance updatedprevious version archived

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionEnsure the patient's medical record fully documents history, exam, and diagnostic test results to support medical necessity and make records available on request.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying that medical records documentation may be required to assess whether the member meets clinical criteria for coverage and does not guarantee coverage.

Updated definitions for Arthrodesis, Interlaminar Lumbar Instrumented Fusion (ILIF), Interlaminar Stabilization Device, and Neurogenic Claudication.

Updated Clinical Evidence and References sections to reflect the most current information and archived previous policy version CS363NM.B.

Updated Clinical Evidence and References sections to reflect the most current information.

Archived previous policy version CS363NM.B.

single statepolicy application

grade 1max spondylolisthesis allowed

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CS363NM.Barchived prior version

limited/lowevidence quality

Coverage Criteria for Interspinous Devices

Interspinous Fixation (Fusion) — Medical Necessity

Covered when ALL of the following are met

Interspinous fixation (fusion) device coverage criteria: Device is used for interspinous fixation (fusion) and performed according to FDA labeled indications, contraindications, warnings, and precautions

supporting requirement

Clinical indication: Back pain of discogenic origin, with degeneration of the disc confirmed by history and radiographic studies

Spondylolisthesis: No more than grade 1 spondylolisthesis<= grade 1

Surgical use: Used with an interbody cage as an adjunct to fusion at a single lumbar level (L1-S1)single level

Static interspinous distraction device — indication criteria

Covered when ALL of the following are met

Indication criteria: Clinically symptomatic degenerative lumbar stenosis associated with neurogenic claudication relieved by flexion; sitting for at least 50 minutes without pain; able to walk at least 50 feet; mild to moderate stenosis on CT/MRI (25-50% reduction in lateral/central foraminal diameter compared to adjacent levels); failure of 6 months of nonoperative treatment; no more than 25° degenerative scoliosis; no more than Grade I degenerative spondylolisthesis; open surgery (e.g., laminectomy) is not a medically safe option due to comorbidities.see individual nodes

Per NASS 2025 recommendations

Static interspinous distraction device — exclusions

Not indicated when ANY of the following are present

Contraindications: Degenerative spondylolisthesis of Grade II or higher; degenerative scoliosis greater than 25°; dynamic instability at the operative level (e.g., on flexion-extension views); symptoms not relieved by flexion; patient is medically suitable for a direct decompressive procedure (e.g., laminectomy); primarily axial back pain unrelated to activity; BMI >= 40; fixed motor deficit; prior lumbar surgery at the intended level.

Per NASS 2025

Interspinous fixation with fusion — allowed scenarios

Covered as adjunct to fusion when ALL of the following apply

Adjunct-to-fusion criteria: Used in the context of lumbar fusion for diagnoses such as stenosis, disc herniation, or synovial facet cysts; utilized with robust open laminar and/or facet decortication and fusion and/or robust autograft inter- and extra-spinous process decortication and fusion and/or interbody fusion of the same motion segment; may be used as an adjunct to cyst excision involving removal of >50% of the facet joint.

Per NASS 2025

Interspinous fixation — explicit exclusions

Not indicated in the following situations

Not indicated: Spondylolisthesis greater than Grade I; bilateral isthmic spondylolysis; significant dynamic instability (e.g., on flexion-extension views); scoliosis or coronal/rotatory instability; fusion indicated at more than one lumbar level; generally not indicated at L5-S1 because of mechanical limitations of S1 spinous processes (except when anatomy is favorable); complete resection of the facet (unless accompanied by interbody fusion); disc herniation or stenosis adjunct use in the absence of instability or spondylolisthesis; discogenic low back pain; when fusion is otherwise not indicated per NASS lumbar fusion recommendations.

Per NASS 2025

Interspinous decompression and interlaminar stabilization systems without fusion are considered unproven and not medically necessary for the treatment of spine pain or lumbar spinal stenosis due to insufficient evidence of efficacy. By contrast, interspinous fixation (fusion) devices are considered proven and medically necessary only when used in accordance with FDA labeled indications and when all of the following are met: documented discogenic back pain with radiographic confirmation of disc degeneration; no more than Grade 1 spondylolisthesis; and the device is used as an adjunct with an interbody cage for a single-level lumbar fusion (L1–S1).

Interspinous distraction devices without fusion are not indicated outside the specific parameters described by the North American Spine Society (NASS 2025). Indication is limited to carefully selected patients with symptomatic degenerative lumbar stenosis who meet criteria such as neurogenic claudication relieved by flexion, the ability to sit at least 50 minutes without pain, the ability to walk at least 50 feet, mild to moderate stenosis on imaging (≈25–50% reduction in foraminal/central diameter), failure of 6 months of nonoperative treatment, ≤ 25° degenerative scoliosis, ≤ Grade I spondylolisthesis, and when open decompression is not medically safe due to comorbidities.

This policy is informational and does not replace plan terms. Coverage determinations must conform to the member’s applicable federal, state, or contractual benefit plan requirements; in the event of a conflict, those requirements govern. Before applying this policy, verify the member’s benefit plan language and any plan-specific authorization or utilization management tools that may apply.

Summary decision: interspinous devices that are implanted without fusion (including interspinous spacers and interlaminar stabilization devices) are considered not medically necessary/unproven for routine treatment of lumbar spinal stenosis. Devices affixed to spinous processes that are intended to promote fusion are considered medically necessary when used as adjuncts to interbody fusion and meet the specific clinical and device-use criteria (FDA labeling, documented discogenic pain, ≤ Grade 1 spondylolisthesis, single-level use L1–S1).

The clinical evidence base for interspinous decompression devices without fusion is limited and of generally low quality; existing studies are often small or have methodological limitations. Systematic reviews and trials report inconsistent benefits and raise safety concerns, including a reported higher reoperation risk in some analyses. Larger, well-designed, long-term comparative trials are needed to establish safety and effectiveness compared to standard decompression.

Coding and Key Parameters

Applicable CPT Codes (group 1)CPT

22853

Insertion of interbody biomechanical device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for device anchoring, in conjunction with interbody arthrodesis, each interspace

Applicable CPT Codes (group 2)CPT

22854	Insertion of intervertebral biomechanical device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for device anchoring, in conjunction with interbody arthrodesis
22859	Insertion of intervertebral biomechanical device(s) to intervertebral disc space or vertebral body defect without interbody arthrodesis
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
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
22899	Unlisted procedure, spine [when specified as insertion of a non-pedicle interspinous process fixation device]

Conservative therapy duration — 6 months

Conservative therapy duration6 months of nonoperative treatment prior to consideration of static interspinous distraction devices

Source contextPer NASS 2025 recommendations for interspinous distraction devices

Related noteRequired failure of conservative care applies to static devices used instead of direct decompression

Scoliosis limit for indication — <= 25 degrees

Scoliosis limitDegenerative scoliosis must be no more than 25 degrees for static interspinous distraction device indication

Contraindication threshold

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization and Coding Reference

Prior authorization and coding reference: This policy includes an Applicable Codes list (22853, 22854, 22859, 22867-22870, 22899) for provider reference. Inclusion of a code in this policy is for reference only and does not guarantee coverage or payment; coverage is determined by federal, state, or contractual requirements and applicable laws.

CPT codes referenced: 22853, 22854, 22859, 22867, 22868, 22869, 22870, 22899

Note

Follow NASS 2025 Recommendations

Follow NASS 2025 recommendations: Use and coverage should align with the North American Spine Society (NASS) 2025 guidance presented in this policy. NASS updated recommendations clarify appropriate indications for use of interspinous devices (notably that fixation devices should be used as adjuncts to robust fusion techniques and that interspinous fixation without open decortication and fusion or interbody fusion is not supported). For static interspinous distraction devices used instead of direct decompression, NASS 2025 specifies strict diagnostic and clinical qualification criteria (e.g., neurogenic claudication relieved by flexion, imaging-confirmed mild–moderate stenosis, failure of 6 months of nonoperative treatment, limits on scoliosis and spondylolisthesis, and other exclusions).

Background and Clinical Context

Lumbar spinal stenosis (LSS) is a degenerative narrowing of the spinal canal that can produce neurogenic claudication and leg and back pain. Surgical management options include direct decompression (laminectomy) with or without fusion. Interspinous fixation devices are intended to provide stabilization and promote fusion when used as an adjunct to interbody fusion, whereas interspinous process decompression (spacers) and interlaminar stabilization devices aim to provide indirect decompression and symptomatic relief for selected patients who meet strict clinical and imaging criteria.

Definitions

Interspinous Fixation Devices — definition and intended use

DefinitionDevices intended for attachment to the spinous processes to achieve stabilization and promote fusion in patients with degenerative disc disease

Intended useUsed as an adjunct to lumbar fusion (e.g., with interbody cage, open decortication and fusion techniques) to stabilize posterior elements

ScopeApplied in the context of interbody or posterior fusion at a single lumbar level (L1–S1) when performed per FDA labeling and NASS recommendations

Interspinous Process Decompression (IPD) — definition

DefinitionMinimally invasive procedure that implants a spacer between spinous processes to distract neural foramen and decompress nerves (interspinous process decompression, IPD)

Clinical context

Policy Revision History

2026-01-01revisionLatest

Added language clarifying medical records documentation that may be required to assess member eligibility for coverage; documentation must be legible and available on request.

revision

Updated Clinical Evidence and References sections to reflect the most current information and archived previous policy version CS363NM.B.

revision

Policy Summary

PayerUnitedHealthcare

PolicyInterspinous Fusion and Decompression Devices (for New Mexico Only)

Policy CodePolicy CS363NM.C

Change TypeClinical evidence and documentation guidance updatedprevious version archived

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionEnsure the patient's medical record fully documents history, exam, and diagnostic test results to support medical necessity and make records available on request.

SourceLink

On This Page

Degenerative scoliosis greater than 25° is NOT indicated

Source contextNASS 2025 coverage recommendations

Maximum spondylolisthesis grade for indication — Grade I

Maximum spondylolisthesis gradeNo more than Grade I degenerative spondylolisthesis for static interspinous distraction device indication

ExclusionDegenerative spondylolisthesis of Grade II or higher is NOT indicated

Related fusion guidanceInterspinous fixation affixed to spinous processes also should not be used when spondylolisthesis > Grade I per NASS 2025

Sitting tolerance for symptom characterization — at least 50 minutes without pain

Sitting tolerance requirementPatient can sit for at least 50 minutes without pain (relief of neurogenic claudication with flexion)

Clinical relevancePart of symptomatic criteria for clinically symptomatic degenerative lumbar stenosis per NASS 2025

Assessment methodDocumented history of symptom relief with flexion and sitting tolerance on clinical evaluation

Walking distance for symptom characterization — at least 50 feet

Walking distance requirementPatient is able to walk at least 50 feet as part of symptom characterization for static devices

Clinical contextUsed with other findings (neurogenic claudication relieved by flexion and imaging evidence of mild–moderate stenosis)

DocumentationRecord of walking tolerance should be included in medical record supporting indication

BMI exclusion threshold — >= 40

BMI exclusion thresholdBMI ≥ 40 is listed as a contraindication for static interspinous distraction devices

ImplicationPatients with BMI >= 40 are NOT indicated for interspinous distraction devices per NASS 2025

Related criteriaConsideration of comorbidities and surgical candidacy should be documented

Interspinous fusion devices: use as adjunct to fusion per NASS 2025 (see policy text)
Interspinous decompression/distraction devices: NASS 2025 defines specific qualifying criteria and exclusions, including 6 months nonoperative therapy failure

Documentation Required

Medical Records Documentation and Denial Risk

Medical records documentation and denial risk: The patient's medical record must fully support the medical necessity of requested services. Documentation should include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or imaging. Lack of adequate, legible documentation that supports the clinical criteria may result in denial of coverage.

Ensure documentation is legible, maintained in the medical record, and available upon request
Documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage

Note

No Specified Prior Authorization or Denial Triggers

Authorization and denial triggers: This section does not specify plan-governed prior authorization processes, explicit prior authorization codes, or automatic denial triggers. Providers must verify any prior authorization requirements, billing rules, and approval processes with the member's applicable federal, state, or contractual benefit plan.

No prior authorization codes or requirements are listed in this policy excerpt
In the event of conflict, federal/state/contractual benefit plan requirements govern coverage determinations

Step Therapy

Step Therapy/Quantity Limits Not Specified

Step therapy and quantity limits: This section does not contain step therapy requirements or quantity‑limit constraints. No step therapy information is mentioned in the policy excerpts.

No step therapy requirements present in this section
No quantity limits specified

Denial Risk

Conflicts with Benefit Plan Requirements

Conflicts with benefit plan requirements: Benefit coverage is determined by the federal, state, or contractual requirements and applicable laws, which may differ from this policy. If there is a conflict between this Medical Policy and a member's benefit plan, the federal/state/contractual requirements for that benefit plan govern. Verify plan-specific requirements before submitting claims or performing services.

Check applicable benefit plan requirements prior to using this policy
Failure to follow plan terms may result in denial or nonpayment

Used to treat lumbar spinal stenosis after failure of conservative measures to relieve symptoms

MechanismSpacer is opened/expanded to distract and provide dynamic stabilization, blocking stenosis-related lumbar extension

Interlaminar Stabilization Device — definition

DefinitionAn implantable interspinous process device intended to provide symptomatic relief of claudicatory lumbar spinal stenosis by reducing lumbar extension while preserving other ranges of motion

Implant descriptionTypically inserted between adjacent spinous processes and may be implanted after decompression at affected level(s)

Functional goalProvide indirect decompression and symptomatic relief of neurogenic claudication

Static interspinous distraction device — definition per NASS/FDA labeling

NASS/FDA definitionStatic interspinous distraction devices are nonflexible/noncompressible implants intended to provide indirect decompression of neural elements and may be used instead of a direct decompressive procedure

Indication contextNASS 2025 applies these recommendations only to static devices intended to be used instead of direct decompression

Clinical criteria linkageUse is conditioned on symptom criteria (e.g., neurogenic claudication relieved by flexion), imaging evidence of mild–moderate stenosis, and failure of 6 months nonoperative care

Dynamic interspinous device — definition per NASS and FDA labeling

NASS/FDA definitionDynamic interspinous devices are implants that, per FDA labeling and NASS guidance, are intended to be used in conjunction with a direct decompression (e.g., laminectomy)

DistinctionDynamic devices differ from static devices in that they are adjuncts to direct decompression rather than replacements for it

Usage noteFollow FDA labeling and NASS 2025 recommendations regarding combination with decompression procedures

Updated Clinical Evidence and References sections to reflect the most current information and archived previous policy version CS363NM.B.

revision

Updated Clinical Evidence and References sections to reflect the most current information; archived previous policy version CS363NM.B.

revision

Updated Clinical Evidence and References sections to reflect the most current information and archived previous policy version CS363NM.B.

revision

Multiple entries noting updates to Clinical Evidence and References and archiving of previous policy version CS363NM.B.

revision

Policy history updated: Clinical Evidence and References sections refreshed; previous policy version CS363NM.B archived.

revision

Summary of Changes entry updated to note Clinical Evidence and References revisions and archival of CS363NM.B.

revision

Revision entry recording updates to Clinical Evidence and References and archiving of previous policy version CS363NM.B.

revision

Multiple Policy History entries indicating Clinical Evidence and References were updated and CS363NM.B was archived.