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Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)

Section: Surgery
Effective Date: July 01, 2018
Revised Date: May 14, 2018

Description

The development of interspinous distraction devices has emerged as an alternative treatment for lumbar stenosis. These devices are intended to restrict painful motion while otherwise enabling normal motion of the spine. It is implanted between the spinous processes of the lumbar spine, using a minimally invasive procedure. The device is designed to act as a spacer between the spinous processes, maintaining flexion and limiting extension of the lumbar spine. This prevents nerve impingement, and relieves symptoms of pain.

Criteria

Lumbar (non-fusion) stabilization with the Coflex Interlaminar Technology 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 patients 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
  • Skeletally mature individual; 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 6 months of conservative treatment (such as anti-inflammatory medication, physical therapy).

Note:

The Coflex device is not to be used accompanying a fusion at the treatment level. Insertion of any other interlaminar stabilization device is considered experimental/investigational and, therefore, non-covered as there is insufficient data to prove the efficacy and safety of these other devices.

The implantation of interspinous distraction devices for treatment of spinal stenosis is considered experimental/investigational and, therefore, non-covered. The current available scientific data remains inadequate to permit scientific conclusions regarding the long-term advantages of minimally invasive interspinous distraction devices over standard surgical options in the treatment of spinal stenosis.

Procedure Codes

22899 22867 22868 22869 22870

Outpatient HCPCS (C Codes)

C1821

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 22867, 22868, 22869, and 22870

M48.061 M48.062 M43.06

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