Humana Commercial Clinical Policy

Humana Interspinous Process Decompression Spacers Form

Effective Date

08/24/2023

Last Reviewed

NA

Original Document

  Reference



Description

Interspinous process decompression, also known as interspinous process distraction, is a minimally invasive surgical procedure that is proposed to relieve the symptoms of lumbar spinal stenosis in an individual who does not respond to conservative, nonsurgical treatment. The procedure involves implanting spacers between the spinous processes of the vertebrae which appear to be the source of the symptoms, purportedly creating more space for the spinal cord and nerves in the spinal canal. The spacers can be implanted at one or two lumbar levels and are designed to remain in place without being permanently affixed to the bone or ligamentous structures of the spine.

An example of a US Food & Drug Administration (FDA) approved interspinous process spacer includes, but may not be limited to, the Superion Indirect Decompression System. Use of the Superion device may also be referred to as the Vertiflex procedure.

NOTE:

Interspinous process decompression spacers differ from dynamic spinal stabilization devices. For information regarding dynamic spinal stabilization devices including, but not limited to, the coflex Interlaminar Stabilization Device, please refer to Dynamic Spinal Stabilization Devices Medical Coverage Policy.

Coverage Determination

Humana members may NOT be eligible under the Plan for placement of interspinous process decompression spacers including, but may not be limited to, the Superion Indirect Decompression System. These are considered experimental/ investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional information about back pain and spinal stenosis may be found from the following websites:
  • American Academy of Neurology
  • National Library of Medicine
  • North American Spine Society

Medical Alternatives

Alternatives to interspinous process decompression spacers include, but may not be limited to, the following:

  • Bracing (please refer to Orthotics Medical Coverage Policy)
  • Epidural steroid injection (please refer to Injections for Chronic Pain Conditions Medical Coverage Policy)
  • Laminectomy or laminotomy (please refer to Spinal Decompression Surgery Medical Coverage Policy)
  • Physical therapy (please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy)
  • Prescription drug therapy
  • Spinal fusion surgery (please refer to Spinal Fusion Surgery Medical Coverage Policy)

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes.

Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

CPT® Code(s)

  • 22869 - Insertion of interlaminar/interspinous process stabilization/ distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level - Not Covered
  • 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) - Not Covered

Code(s) identified:

  • No code(s) HCPCS
  • Code(s) C1821 - Interspinous process distraction device (implantable) - Not Covered
Interspinous Process Decompression Spacers

Effective Date: 08/24/2023
Revision Date: 08/24/2023
Review Date: 08/24/2023
Policy Number: HUM-0308-017
Page: 4 of 5

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

References

  1. Chou R, Loeser J, Owens D, et al. Interventional therapies, surgery and interdisciplinary rehabilitation for low back pain – an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009;34:1066-1077.
  2. Deer T, Grider J, Pope J, et al. The MIST guidelines: The Lumbar Spinal Stenosis Consensus Group guidelines for minimally invasive spine treatment. Pain Pract. 2019;19(3):250-274.
  3. ECRI Institute. Clinical Evidence Assessment. Superion Indirect Decompression System (Boston Scientific Corp.) for treating lumbar spinal stenosis. https://www.ecri.org. Published June 20, 2019. Updated August 19, 2022. Accessed July 26, 2023.
  4. ECRI Institute. Health Technology Forecast. Research group recommends against interspinous process spacers for treating lumbar spinal stenosis. https://www.ecri.org. Published December 12, 2013. Accessed July 26, 2023.
  5. Hayes, Inc. Evolving Evidence Review. Superion Interspinous Spacer System (Vertiflex) for treatment of neurogenic claudication caused by spinal stenosis. https://evidence.hayesinc.com. Published September 17, 2021. Updated April 21, 2023. Accessed July 28, 2023.
  6. Hayes, Inc. Prognosis Overview (ARCHIVED). DIAM (device for intervertebral assisted motion) spinal stabilization system. https://evidence.hayesinc.com. Published February 29, 2016. Accessed July 28, 2023.
  7. MCG Health. Spinal distraction devices. 27th edition. https://www.mcg.com. Accessed July 7, 2023.
  8. North American Spine Society (NASS). Coverage Policy Recommendations. Interspinous devices without fusion. https://www.spine.org. Published May 2014. Accessed August 14, 2023.
  9. North American Spine Society (NASS). Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care. Diagnosis and treatment of degenerative lumbar

Interspinous Process Decompression Spacers Effective Date: 08/24/2023
Revision Date: 08/24/2023
Review Date: 08/24/2023
Policy Number: HUM-0308-017
Page: 5 of 5

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  1. Onggo J, Nambiar M, Maingard J, et al. The use of minimally invasive interspinous process devices for the treatment of lumbar canal stenosis: a narrative literature review. J Spine Surg. 2021;7(3):394-412. https://www.ncbi.nlm.nih.gov. Accessed August 16, 2022.
  2. Tapp S, Brook M, Tostenson T, et al. Understanding the value of minimally invasive procedures for the treatment of lumbar spinal stenosis: the case of interspinous spacer devices. Spine J. 2018;18:584-592.
  3. UpToDate, Inc. Lumbar spinal stenosis: treatment and prognosis. https://www.uptodate.com. Updated July 2023. Accessed August 11, 2023.
  4. US Food & Drug Administration (FDA). Premarket Approval (PMA). Superion Interspinous Spacer. https://www.fda.gov. Published June 18, 2015. Accessed April 6, 2016.
  5. Welton L, Krieg B, Trivedi D, et al. Comparison of adverse outcomes following placement of Superion Interspinous Spacer device versus laminectomy and laminotomy. Int J Spine Surg. 2021;15(1):153-160. https://www.ijssurgery.com. Accessed August 11, 2023.
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