Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Lumbar (non-fusion) stabilization with FDA approved interlaminar or interspinous stabilization devices for treatment of spinal stenosis, following direct surgical decompression, may be considered medically necessary for one- or two-level use, when
ALL
of the following criteria are met:
-
Lumbar stenosis from L1-L5 in skeletally mature individuals with at least moderate impairment in function, who experience relief in flexion from their symptoms of leg/buttocks/groin pain, with or without back pain, who have significant risk for spinal instability with decompression alone;
and
-
Diagnosis of lumbar spinal stenosis with up to grade I spondylolisthesis, confirmed by imaging and clinical exam;
and
-
Stenosis-related disability impacting activities of daily living, with or without mild-to-moderate back pain;
and
-
Completion and failure of at least six (6) months of conservative treatment, such as (not an all-inclusive list):
-
Anti-inflammatory medication;
or
- Physical Therapy
Note: The FDA approved interlaminar or interspinous stabilization devices is not to be used accompanying a fusion at the treatment level.
The implantation of interspinous distraction devices for treatment of spinal stenosis (i.e., Minuteman Procedure) is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer reviewed literature regarding the long-term advantages of minimally invasive interspinous distraction devices over standard surgical options in the treatment of spinal stenosis.
Procedure Codes
22612 | 22867 | 22868 | 22869 | 22870 |