Highmark Commercial Medical Policy - West Virginia |
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:
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.
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) |
C1821 |
Links |
06/2015, Place of Service Designated as Inpatient/Outpatient for Interspinous and Interlaminar Stabilization/Distraction Devices
11/2017- Revised Criteria for Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)