22869
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
6.85
Facility
$395.13
Non-Facility
$395.13
Documentation Required
- Degeneration of the disc must be "confirmed by history and radiographic studies."
- Documentation that the interspinous fixation device is used with an interbody cage as an adjunct to fusion at a single level in the lumbar spine (L1-S1).
- Documentation of the grade of spondylolisthesis (must be no more than grade 1).
- Procedures must be "performed according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions" (documentation of device indication/labeling and adherence may be required).
Key Coverage Criteria
- Interspinous fixation (fusion) devices are proven and medically necessary when performed according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions and all of the following criteria are met:
- Used with an interbody cage as an adjunct to fusion at a single level in the lumbar spine (L1-S1)
- Back pain of discogenic origin, with degeneration of the disc confirmed by history and radiographic studies
- No more than grade 1 spondylolisthesis
- North American Spine Society (NASS) position (2019): interspinous fixation with fusion for stabilization may be considered when utilized in the context of lumbar fusion procedures for patients with diagnoses including stenosis, disc herniations, or synovial facet cysts in the lumbar spine, as an adjunct to cyst excision which involves removal of greater than 50 percent of the facet joint, and when utilized in conjunction with robust open laminar and/or facet decortication and fusion and/or inter [...]
- Epiduroscopy / epidural lysis of adhesions: proposed for diagnosis/treatment of intractable LBP (including failed back surgery syndrome) by visualizing and lysing adhesions and injecting medications (insufficient high-quality evidence to support routine clinical use).
8 Active Policies
AMBETTER-CP.MP.114 — Disc Decompression Procedures
UHC-POL-interspinous-fusion-decompression-devices — Interspinous Fusion and Decompression Devices
UMR-POL-UMR-interspinous-fusion-decompression-devices — Interspinous Fusion and Decompression Devices
SUREST-POL-SUREST-interspinous-fusion-decompression-devices — Interspinous Fusion and Decompression Devices
Related Codes
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