Highmark Commercial Medical Policy - West Virginia

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Medical Policy: S-191-016
Topic: Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
Section: Surgery
Effective Date: November 6, 2017
Issue Date: November 6, 2017
Last Reviewed: October 2017

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.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

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).


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

Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

The implantation of interspinous distraction devices or dynamic spine stabilization for the treatment of spinal stenosis or degenerative spine disorders is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Outpatient HCPCS (C Codes)



This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Highmark West Virginia plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Highmark West Virginia retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark West Virginia. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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