*** This policy was implemented in the absence of National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) coverage criteria. This policy applies to all Blue Medicare HMO, Blue Medicare PPO, Healthy Blue + MedicareSM (HMO-POS D-SNP), Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services. ***

Description of Procedure

Interspinous and interlaminar implants (spacers) stabilize or distract the adjacent lamina and/or spinous processes and restrict extension to reduce pain in individuals with lumbar spinal stenosis and neurogenic claudication. Interspinous spacers are small devices implanted between the vertebral spinous processes. After implantation the device is opened or expanded to distract (open) the neural foramen and decompress the nerves. Interlaminar spacers are implanted midline between adjacent lamina and spinous processes to provide dynamic stabilization following decompression surgery or as an alternative to decompression surgery.

One type of interspinous implant is inserted between the spinous processes through a small (4 to 8 cm) incision and acts as a spacer between the spinous processes, maintaining the flexion of that spinal interspace. The supraspinous ligament is maintained and assists in holding the implant in place. The surgery does not include any laminotomy, laminectomy, or foraminotomy at the time of insertion, thus reducing the risk of epidural scarring and cerebrospinal fluid leakage. Other interspinous spacers require removal of the interspinous ligament and are secured around the upper and lower spinous processes.

Interlaminar spacers are implanted midline between adjacent lamina and spinous processes to provide dynamic stabilization either following decompression surgery or as an alternative to decompression surgery. Interlaminar spacers have 2 sets of wings that are placed around the inferior and superior spinous processes. These may be referred to as interlaminar implants or an interspinous U. These implants aim to restrict painful motion while otherwise enabling normal motion. The devices (spacers) distract the laminar space and/or spinous processes and restrict extension. This procedure theoretically enlarges the neural foramen and decompresses the cauda equina in individuals with spinal stenosis and neurogenic claudication. Other types of dynamic posterior stabilization devices are pedicle screw/rod-based devices and total facet replacement systems; these are not covered in this policy.

Policy Statement

Interspinous or interlaminar distraction devices as a stand-alone procedure are considered investigational for all applications. Use of an interlaminar stabilization device following decompression surgery is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures.

Benefit Application

Please refer to the member’s individual Evidence of Coverage (EOC) for benefit determination.  Coverage will be approved according to the EOC limitations if the criteria are met.

Coverage decisions will be made in accordance with:

• The Centers for Medicare & Medicaid Services (CMS) national coverage decisions;
• General coverage guidelines included in original Medicare manuals unless superseded by operational policy letters or regulations; and
• Written coverage decisions of local Medicare carriers and intermediaries with jurisdiction for claims in the geographic area in which services are covered.

Benefit payments are subject to contractual obligations of the Plan.  If there is a conflict between the general policy guidelines contained in the Medical Coverage Policy Manual and the terms of the member’s particular Evidence of Coverage (E.O.C.), the E.O.C. always governs the determination of benefits.

Definitions

Dynamic Spinal Stabilization (DSS), also referred to as soft stabilization or flexible stabilization, is a surgical procedure that uses implantable devices designed to stabilize the spine while preserving motion at the affected spinal segment(s). Unlike traditional spinal fusion, which eliminates movement at stabilized levels, DSS aims to maintain some degree of natural spine motion and reduce mechanical stress on adjacent segments. These systems may include flexible rods, motion-preserving pedicle screw systems or interspinous/interlaminar devices that provide stability. DSS is most commonly proposed for the treatment of spondylolisthesis or spinal stenosis as an alternative to spinal fusion. Examples of DSS devices include, but not limited to, ApiFix System, Coflex Interlaminar Stabilization System, Dynesys Stabilization System, LimiFlex Dynamic Sagittal Tether, Stabilimax NZ, TOPS and VersaTie System

Interlaminar Spacers are implanted devices used to provide dynamic stabilization either with decompression surgery or as an alternative to decompression surgery.

Interspinous Implants are small devices implanted between the vertebral spinous processes, used to distract the neural foramina and decompress the nerves.

Spacer Devices stabilize the spine and reduce the pressure on affected nerve roots.

Lumbar Spinal Stenosis (LSS) is a narrowing of the central spinal canal, lateral spinal recesses and/or neural foramina, resulting in pain and mobility issues.

Indications for Coverage

Not applicable as these services are considered Investigational and Experimental

When Coverage Will Not Be Approved

Interspinous or interlaminar distraction devices as a stand-alone procedure are considered investigational as a treatment of spinal stenosis.

Use of an interlaminar stabilization device following decompression surgery is considered investigational for all applications.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes.  Inclusion of a code in the section does not guarantee reimbursement.

Applicable codes: 22867, 22868, 22869, 22870, 22899, C1821

The Plan may request medical records for determination of medical necessity.  When medical records are requested, letters of support and/or explanation are often useful but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Special Notes

Please also review Medicare Part C Medical Policy Investigational (Experimental) Services

References

1. BCBSNC Commercial Policy: Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) via Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) | Providers | Blue Cross NC
   https://www.bluecrossnc.com/providers/policies-guidelines-codes/commercial/surgery/updates/interspinous-and-interlaminar-stabilization-distraction-devices
2. BCBS Michigan Medicare Advantage: Interspinous/Interlaminar Stabilization/Distraction Devices(Spacers) accessed on 5/12/2026 
3. Human Medicare Advantage Medical Coverage Policy: Dynamic Spinal Stabilization and Vertebral Body Tethering for Spinal Deformities accessed on 5/12/2026
4. United Healthcare Medicare Advantage: Spine Procedures accessed on 05/12/2026

Policy Implementation/Update Information:

Revision date: May 19, 2026: Newly created policy in absence of NCD or LCD. (AR)

Approval Dates:

Medical Coverage Policy Committee: May 21, 2026

Physician Advisory Group Committee: May 19, 2026