MINIMALLY INVASIVE SPINE PROCEDURES · GUIDE 04 OF 04
Interspinous Spacer Procedures
Interspinous & interlaminar stabilization / decompression devices — the category Superion® (without decompression) vs. coflex® (with decompression)
A comprehensive operational reference on the interspinous and interlaminar spacer category for lumbar spinal stenosis: the two device families that define it, the single coding decision that separates them, medical necessity, Medicare and commercial coverage, prior authorization workflow, and denial prevention. This is the category companion to the device-specific Vertiflex guide (Guide 02); the two families are the stand-alone spacer placed WITHOUT open decompression (Superion) and the interlaminar device placed WITH open decompression (coflex).
MSK Specialty Procedure Library™Clinical Procedure Guide Standard v1.0GoHealthcare Practice Solutions
1. Evidence at a Glance
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This one-page executive summary orients prior authorization, utilization management, revenue cycle, and clinical teams to the category as a whole. Device-specific detail for Superion is expanded in Guide 02; every entry here is sourced later in this guide.
Domain Summary
The category Small implants placed at the interspinous or interlaminar space to limit extension and
relieve neurogenic claudication in lumbar spinal stenosis. Two families: placed WITHOUT open decompression (Superion) and placed WITH open decompression (coflex).
The coding hinge 22869 / +22870 = device WITHOUT open decompression (Superion). 22867 / +22868 =
device WITH open decompression (coflex). Choosing the wrong pair misrepresents the procedure and is the category's defining coding error.
FDA status Superion — PMA P140004 (2015). coflex — PMA P110008 (2012). Both are
premarket-approved. The earlier X-STOP spacer was withdrawn in 2015.
Medicare No NCD and no active MAC LCD for interspinous/interlaminar spacers (the prior First
Coast LCD was retired April 2020). Coverage is adjudicated on medical necessity aligned to each device's FDA indication.
Commercial Stand-alone spacers (Superion) are broadly experimental/investigational across major coverage national payers. coflex used with decompression is plan-dependent — some plans allow it
with laminectomy per NASS, others deem it investigational.
Evidence level Superion: randomized two-year and durable five-year data (comparator was another
spacer). coflex: randomized non-inferiority to decompression-plus-fusion (Davis 2013), with long-term data noting a meaningful reoperation rate, especially with instability.
Image guidance Fluoroscopy for spacer placement; coflex additionally involves an open decompression.
Pre-procedure MRI/CT documents stenosis severity and anatomy.
Prior authorization Effectively mandatory; frequently delegated to eviCore or Carelon. Expect investigational
denials for stand-alone spacers.
Conservative At least 6 months of non-operative treatment is embedded in both FDA indications.
therapy
Key documentation Stenosis severity; neurogenic claudication with relief in flexion; listhesis grade; level count
(one or two, L1-L5); failed 6-month conservative care; whether open decompression is performed (drives code selection).
Approval Match device to anatomy and code to procedure: stand-alone spacer for moderate LSS considerations without decompression (22869), interlaminar device when decompression is performed
(22867). Severe instability and greater-than-Grade-1 listhesis undermine candidacy.
2. Overview
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Interspinous and interlaminar spacers are small implants placed between adjacent spinous processes or lamina in the lumbar spine. By holding the posterior space open and restricting painful extension, they indirectly enlarge the canal and neural foramina in the standing and walking positions where neurogenic claudication occurs. The category is unified by that mechanism and by a shared code family, but it splits cleanly into two clinical and coding groups.
The stand-alone group is placed percutaneously without any open decompression; the Superion Indirect Decompression System is the only such device currently marketed in the United States, and it is covered in device-specific depth in Guide 02. The with-decompression group is implanted after an open surgical decompression to provide interlaminar stabilization; coflex is the representative device. A third device, X-STOP, defined the early category but was withdrawn in 2015. Understanding which group a case belongs to determines the CPT® pair, the payer posture, and the documentation burden — which is why this category page leads with that distinction and returns to it throughout.
3. Relevant Anatomy (High-Level)
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Degenerative lumbar spinal stenosis narrows the central canal, lateral recesses, and neural foramina through ligamentum flavum hypertrophy, facet arthropathy, and disc bulging, producing neurogenic claudication that worsens in extension and eases in flexion. Interspinous spacers sit in the interspinous space and transmit load to the spinous processes; interlaminar devices such as coflex are implanted midline between adjacent lamina. In both cases, spinous-process and laminar bone quality and integrity are prerequisites — osteoporosis or a prior fracture at the level compromises fixation. Anatomy here is limited to what drives candidacy and coverage.
4. Clinical Indications
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The two device families carry distinct, narrow FDA indications:
Superion (stand-alone, without decompression)
- Skeletally mature patients with neurogenic intermittent claudication secondary to moderate
degenerative LSS.
- With or without Grade 1 spondylolisthesis; relief in flexion; failed at least 6 months of conservative
care; one or two contiguous levels. coflex (with decompression)
- One- or two-level lumbar stenosis from L1-L5 in skeletally mature patients with at least moderate
impairment in function.
- Relief in flexion from leg/buttock/groin pain, with or without back pain; failed at least 6 months of
conservative care.
- Implanted for interlaminar stabilization after open decompression of the stenosis at the affected
level(s).
5. Patient Selection
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- Neurogenic claudication with a positional pattern — worse in extension/standing, better in
flexion/sitting.
- Stenosis severity matched to device: moderate LSS for stand-alone Superion; stenosis treated with
decompression for coflex.
- No greater than Grade 1, stable spondylolisthesis and no dynamic instability (instability predicts
reoperation, especially with coflex).
- Adequate spinous-process and laminar bone quality; no prior fusion or decompressive laminectomy
at the index level.
- Documented functional limitation and a genuine, dated 6-month conservative-care course.
- One or two contiguous lumbar levels (L1-L5).
6. Contraindications
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- Greater-than-Grade-1 spondylolisthesis or dynamic/segmental instability.
- Prior fusion or decompressive laminectomy at any index lumbar level (an explicit coflex
contraindication).
- Severe stenosis or cauda equina syndrome requiring definitive open decompression (for the
stand-alone pathway).
- Osteoporosis or compromised bone quality; prior spinous-process fracture; ankylosed or fractured
posterior elements.
- Significant scoliosis or anatomy that cannot accommodate the device.
- Active systemic or local infection; known titanium allergy.
7. Medical Necessity
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Medical necessity in this category turns on matching the record to the specific device's FDA indication and to the payer's criteria, and on making the with-decompression-or-not question unambiguous, because it drives both coding and coverage. A defensible statement establishes:
- Diagnosis with specificity: lumbar spinal stenosis with neurogenic claudication (ICD-10-CM
M48.062) at the treated level(s).
- Severity matched to device: moderate LSS for stand-alone Superion; stenosis warranting
decompression for coflex.
- Positional symptom pattern: relief in flexion — shared FDA-indication language across the
category.
- Stability: no greater than Grade 1 spondylolisthesis; instability screened and excluded.
- Conservative-care failure: a single dated timeline covering at least 6 months.
- Procedure clarity: whether an open decompression is performed — the fact that selects 22867 vs.
22869.
8. Imaging Requirements
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- MRI (or CT/CT-myelogram) documenting stenosis severity and the anatomic contributors at the
treated level(s).
- Severity stated explicitly — moderate for stand-alone Superion candidacy.
- Spondylolisthesis grade documented as no greater than Grade 1; flexion-extension radiographs
where instability is in question.
- Level and laterality context sufficient to support the specific device and code.
9. Conservative Treatment Requirements
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- At least 6 months of non-operative treatment, embedded in both FDA indications.
- A supervised physical therapy or activity-modification program, with dates and response.
- Pharmacologic management and, where used, epidural steroid injection with dates and outcomes.
- A clear statement that symptoms and functional limitation persisted despite the above, consolidated
on one timeline.
10. CMS / Medicare Coverage
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There is no National Coverage Determination and no active Medicare Administrative Contractor Local Coverage Determination for interspinous or interlaminar spacers. The prior First Coast LCD (L34006) and its companion article were retired in April 2020 and were not replaced. In the absence of an NCD or LCD, coverage is adjudicated case-by-case under the reasonable-and-necessary standard of Section 1862(a)(1)(A), benchmarked to each device's FDA-approved indication. In practice, well-documented cases that track the indication are widely reimbursed by traditional Medicare.
- No NCD and no active MAC LCD/LCA specific to interspinous/interlaminar spacers — confirm current
MAC articles.
- Adjudication is medical-necessity based and benchmarked to the specific device's FDA indication.
- These are device-intensive procedures in the outpatient setting; the implant is reported with HCPCS
C1821 on facility claims.
- Recognized settings: hospital outpatient (POS 22, TOB 13X/85X) and ambulatory surgery center
(POS 24).
- Medicare Advantage plans apply their own utilization management and may be more restrictive;
verify plan-specific rules.
Gohealthcare Prior Authorization Insight
With no LCD, the FDA indication is the criteria set For this whole category, the absence of an LCD means the FDA-approved indication becomes the de facto medical-necessity standard. Build the Medicare record to demonstrate each element for the specific device — severity, neurogenic claudication with relief in flexion, listhesis grade, level count, and failed 6-month conservative care — and make the with-or-without-decompression status explicit so the claim's code matches the operative note. A record that tracks the indication line-by-line is the best protection against a post-payment audit.
11. Commercial Payer Comparison
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Commercial posture divides along the same line that divides the category. Stand-alone interspinous spacers (Superion) are broadly classified as experimental/investigational by the major national payers. coflex used with decompression is more variable: some plans permit it in conjunction with laminectomy consistent with the 2018 NASS coverage recommendation, while others deem interlaminar stabilization investigational, citing increased complications and reoperation versus decompression alone. Utilization management is frequently delegated to eviCore or Carelon. Always verify the member's specific plan and policy version.
Payer / vendor Typical posture (verify current policy)
Cigna (via eviCore) Interspinous spacer/decompression devices, including Superion,
experimental/investigational for all indications (eviCore CMM-608).
Aetna Interspinous distraction devices experimental/investigational; interlaminar stabilization
addressed separately.
UnitedHealthcare Stand-alone interspinous decompression not covered; 2026 policy addresses interspinous
devices largely in the fusion/decompression context.
Humana / Molina Interspinous decompression spacers listed as not covered / experimental-investigational.
Blue Cross Blue Most classify stand-alone spacers as investigational; coflex-with-decompression posture Shield plans varies by plan.
Carelon Where delegated, applies category criteria consistent with an investigational posture for
stand-alone devices; confirm current guideline.
The recurring objection for stand-alone spacers is that the pivotal Superion trial compared the device to another spacer (X-STOP) rather than to surgery or conservative care; for coflex, payers weigh the reoperation signal against decompression alone. Requests and appeals should engage the specific objection for the specific device.
12. Prior Authorization Workflow
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The workflow branches first on device/procedure type (stand-alone vs. with-decompression) and then on benefit type, because those two forks determine both the code and the coverage posture.
Step Action Owner
1. Verify benefits & Identify plan and UM vendor; determine coverage posture for the specific PA / front posture device. office
2. Fork on Stand-alone spacer (22869) vs. device with open decompression (22867) — Clinical / PA procedure type confirm the planned operative approach.
3. Confirm Severity matched to device; neurogenic claudication with relief in flexion; Clinical indication no more than Grade 1 listhesis; one or two levels (L1-L5).
4. Assemble Imaging with severity and level; consolidated 6-month conservative-care PA + clinical evidence packet timeline; functional measures; medical-necessity statement.
5. Submit to correct Route to eviCore, Carelon, or the plan per delegation; use the current portal PA entity and policy version.
6. Track & respond Monitor status; answer clinical pends within the deadline; prepare for PA
peer-to-peer.
7. Authorization & Record the auth number, device, approved code(s)/level(s); ensure C1821 PA / scheduling is captured on the facility claim. scheduling
8. Denial pathway For investigational denials, pursue the plan's exception/medical-necessity PA / physician
appeal engaging the device-specific objection.
13. Common Prior Authorization Denials
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Denial reason Root cause Prevention
Investigational / Plan excludes stand-alone Confirm posture first; pursue a medical-necessity experimental interspinous spacers exception or appeal where excluded.
regardless of documentation.
Coding mismatch Code does not match Select 22869/+22870 for stand-alone placement and
(22867 vs. 22869) whether open 22867/+22868 when decompression is performed; match
decompression was the operative note.performed.
Device code omitted C1821 missing on the Include C1821 on hospital-outpatient/ASC claims.
facility claim for a device-intensive procedure.
Severity / listhesis out Mild or severe stenosis, or Match severity to device; screen stability with of range greater-than-Grade-1 flexion-extension imaging.
listhesis/instability.
Prior surgery at the Prior fusion or laminectomy Confirm a virgin level; document the surgical history. level at the index level (a coflex
contraindication).
Insufficient Missing or undated therapy, Provide a single dated 6-month conservative-care timeline conservative care medication, or injection with outcomes.
history.
14. Appeal Strategies
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- For stand-alone (Superion) investigational denials: cite PMA status and randomized/durable
data, acknowledge the comparator limitation, and request a medical-necessity exception where a categorical exclusion exists.
- For coflex denials: anchor to the with-decompression FDA indication and the randomized
non-inferiority-to-fusion data, and address the reoperation/instability concern by documenting stability and appropriate selection.
- For criteria denials: supply the missing element — severity, listhesis grade, dated conservative
care — and map each to the plan's own criteria.
- Prepare peer-to-peer strategically: brief the physician with severity, positional pattern, stability,
and the exact policy language.
- Close the loop: feed every overturned denial back into the intake checklist.
15. Coding & Billing Overview
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This is an operational coding snapshot, not a full reimbursement methodology. The single most important decision in this category is whether an open decompression is performed, because that one fact selects the entire code pair.
Applicable CPT® codes
CPT® Operational description (paraphrased) Notes
22869 Interlaminar/interspinous device, WITHOUT open decompression or fusion, Stand-alone spacer
including image guidance when performed, lumbar; single level. (Superion). Primarycode.
+22870 Same, second level. Add-on to 22869.
22867 Interlaminar/interspinous device WITH open decompression, without fusion, Device placed with
including image guidance when performed, lumbar; single level. decompression(coflex). Primary code.
+22868 Same, second level (with open decompression). Add-on to 22867.
0171T / Prior Category III codes for spinous-process distraction device. Superseded by the +0172T 22867-22870 family.
Do not use.
HCPCS
- C1821 — interspinous process distraction device (implantable), reported on hospital-outpatient/ASC
facility claims to capture the implant in these device-intensive procedures.
Common ICD-10-CM diagnosis codes
ICD-10-CM Description Billing note
M48.062 Spinal stenosis, lumbar region, with neurogenic claudication. Primary supporting
diagnosis.
M48.061 Spinal stenosis, lumbar region, without neurogenic claudication. Use when
claudication is not documented.
M48.07 Spinal stenosis, lumbosacral region. Use per documented
level.
M43.16 Spondylolisthesis, lumbar region. When Grade 1
spondylolisthesis co-exists; grade must be documented.
M48.06 Spinal stenosis, lumbar region (unspecified). NON-BILLABLE
parent — requires 6th-character specificity (M48.061 / M48.062).
Modifiers, place of service, and ASC considerations
- Code selection: the operative note's decompression status — not the device brand alone — selects
22867 vs. 22869.
- Place of service: 22 (hospital outpatient) or 24 (ASC); TOB 13X/85X for facility claims.
- ASC: confirm the code is on the ASC-payable list and that the C1821 device and device-intensive
packaging are handled correctly.
- Documentation supporting code selection: level(s) treated, whether open decompression was
performed, image guidance, and the specific device.
CPT® is a registered trademark of the American Medical Association. Code descriptions here are paraphrased for operational use; consult the current CPT® code set and payer policy for official language.
16. Device Manufacturers & System Considerations
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The category is defined by a small number of devices with distinct regulatory and design profiles:
- Superion IDS (Boston Scientific): titanium interspinous spacer placed WITHOUT open
decompression; FDA PMA P140004 (2015); the only marketed stand-alone spacer in the U.S.; MR Conditional at 1.5T and 3.0T. See Guide 02 for full device detail.
- coflex Interlaminar Technology (developed by Paradigm Spine; the product line has since
changed corporate ownership): U-shaped titanium-alloy interlaminar device placed WITH open decompression; FDA PMA P110008 (2012); indicated for 1- or 2-level L1-L5 stenosis with interlaminar stabilization after decompression.
- X-STOP (legacy): the early interspinous spacer (Medtronic/Kyphon); withdrawn from the U.S.
market in 2015 and no longer implanted — relevant mainly as the comparator in the Superion pivotal trial.
- Device coding: both current implants are captured on facility claims with HCPCS C1821, and both
are titanium, so MRI teams should apply the manufacturer's current MR-Conditional labeling and patients should disclose the implant.
Gohealthcare Clinical Insight
Match device, procedure, and code as one decision The category's recurring failure is a mismatch among three things that must agree: the device implanted, whether an open decompression was performed, and the CPT® pair billed. Superion without decompression is 22869; coflex with decompression is 22867. When the operative note, the device, and the code all say the same thing, denials and audits on this category largely disappear.
17. Clinical Documentation Checklist
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- ☐ Diagnosis of lumbar spinal stenosis with neurogenic claudication stated explicitly.
- ☐ Stenosis severity documented and matched to the device.
- ☐ Relief in flexion documented (shared FDA-indication language).
- ☐ Spondylolisthesis grade documented as no greater than Grade 1; stability confirmed.
- ☐ Level(s) treated identified (one or two contiguous, L1-L5).
- ☐ Whether an open decompression was performed stated unambiguously (selects 22867 vs.
22869).
- ☐ Consolidated 6-month conservative-care timeline with outcomes.
- ☐ Imaging (MRI/CT) with severity and anatomic contributors named.
- ☐ Correct coding recorded (22867/+22868 or 22869/+22870; C1821 on facility claim; M48.062).
- ☐ Device and benefit-type documented for the authorization record.
18. Procedure Comparison
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Option Mechanism Open decom Implant Primary CPT®
pression?
Superion Indirect: interspinous spacer No Yes 22869 / +22870
(titanium)
coflex Interlaminar stabilization after Yes Yes 22867 / +22868
decompression (titanium) MILD / PILD Direct: debulk ligamentum No (percutane No 62330 / +62331
flavum ous)Laminectom Direct open decompression Yes No 63047 family
y
Reading across the row is the whole game: the decompression column is what separates 22867 from 22869, and the implant column is what separates the spacer category from MILD/PILD. See Guide 01 (MILD/PILD) and Guide 02 (Vertiflex/Superion) for the adjacent detail.
19. GoHealthcare Clinical Insights
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- Decide the code from the operative plan, not the device name — the decompression status is the
deciding fact.
- State stenosis severity and match it to the device: moderate for stand-alone Superion.
- Put ‘relief in flexion’ in the narrative — it is shared FDA-indication language across the category.
- Screen and document stability; instability predicts reoperation, especially with coflex.
- Confirm a virgin level — prior fusion or laminectomy at the index level is an explicit coflex
contraindication.
- Never omit C1821 on the facility claim.
20. GoHealthcare Leadership Perspective
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The interspinous spacer category is a compact lesson in why clinical, coding, and coverage teams must operate as one. A single operative fact — whether an open decompression was performed — determines the CPT® pair, the device-intensive billing, and much of the coverage conversation. When that fact is captured cleanly and flows unchanged from the operative note to the code to the authorization record, the category is routine. When it is blurred, the result is mismatched codes, device-code omissions, and denials that look clinical but are really documentation failures. For an operations leader, the mandate is to make device selection, procedure type, and code selection a single coordinated decision, and to enter commercial cases knowing that stand-alone spacers are broadly investigational while coflex-with-decompression is plan-dependent. Honest posture-setting and tight coding discipline protect the patient's timeline, the clean-claim rate, and the organization's audit posture.
21. GoHealthcare Prior Authorization Insight
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Gohealthcare Prior Authorization Insight
One fact drives the whole claim On this category, the decompression question is the hinge of the entire claim: it selects 22867 versus 22869, shapes the coverage argument, and must match the operative note exactly. The GoHealthcare standard is to confirm the planned approach at intake, confirm coverage posture for the specific device, and reconcile the operative note against the billed code before the claim goes out. That single reconciliation step eliminates the most common and most auditable error in the category.
22. GoHealthcare Case Study
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Clinical scenario A 73-year-old with neurogenic claudication has moderate central and lateral recess stenosis at L4-L5 with ligamentum flavum thickening and Grade 1, stable spondylolisthesis. Symptoms ease with flexion. The patient has failed physical therapy, medication, and two epidural steroid injections and wishes to avoid a fusion.
Documentation and coding challenge The surgeon planned a stand-alone interspinous spacer without decompression, but the pre-authorization request and the draft claim were coded 22867 (with open decompression) by habit. The commercial plan classified stand-alone spacers as investigational.
Resolution strategy The team reconciled the planned approach against the code, corrected it to 22869 for a stand-alone placement, documented moderate severity and Grade 1 stability, consolidated the 6-month conservative-care timeline, and — facing the commercial exclusion — pursued the plan's medical-necessity exception citing PMA status and the randomized and durable data. The C1821 device code was added to the facility claim.
Outcome & lessons learned
- Correcting 22867 to 22869 aligned the code with the operative plan and pre-empted an audit flag.
- The decompression status — not the device name — was the deciding coding fact.
- Matching severity to device and documenting stability strengthened the necessity argument.
- C1821 on the facility claim captured the device-intensive implant correctly.
23. GoHealthcare Best Practices
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- Reconcile the operative plan against the billed code (22867 vs. 22869) before submission.
- Template the medical-necessity narrative around each device's FDA indication.
- State stenosis severity in the request narrative and match it to the device.
- Screen stability with flexion-extension imaging; document a listhesis grade no greater than Grade 1.
- Map 22867/+22868, 22869/+22870, and C1821 in the EHR and charge master.
- Maintain a payer matrix of posture and delegation (eviCore / Carelon) by plan, product, and device.
- Feed every overturned denial back into the intake checklist.
24. Common Mistakes
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- Coding by device name instead of by decompression status (22867 vs. 22869).
- Omitting C1821 on the facility claim for a device-intensive procedure.
- Assuming commercial coverage because the device is FDA-approved and Medicare generally pays.
- Submitting M48.06 (non-billable parent) instead of M48.061 / M48.062.
- Missing greater-than-Grade-1 listhesis, instability, or a prior surgery at the index level.
- Using deleted Category III 0171T/0172T for a 2026 date of service.
- Failing to state stenosis severity, inviting a severity denial.
25. Pearls and Pitfalls
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Pearls & Pitfalls
High-yield reminders Pearl: The decompression column decides the code — 22867 with, 22869 without. Pearl: ‘Moderate stenosis, relief in flexion, up to Grade 1 listhesis’ anchors candidacy across the category. Pitfall: Coding by device brand rather than by whether decompression was performed. Pitfall: Dropping C1821 on the facility claim. Pitfall: Assuming commercial coverage — stand-alone spacers are broadly investigational; coflex-with-decompression is plan-dependent.
26. Frequently Asked Questions
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Q1. What is an interspinous spacer procedure? Placement of a small implant at the interspinous or interlaminar space to limit extension and relieve neurogenic claudication in lumbar spinal stenosis. Q2. What are the two families in this category? Devices placed WITHOUT open decompression (stand-alone spacers, e.g., Superion) and devices placed WITH open decompression (interlaminar stabilization, e.g., coflex). Q3. What is the key coding distinction? 22869/+22870 for placement without open decompression; 22867/+22868 for placement with open decompression. The operative note's decompression status selects the pair. Q4. Which device is stand-alone? Superion (Boston Scientific), the only FDA-approved stand-alone interspinous spacer currently marketed in the U.S. See Guide 02 for device detail. Q5. Which device is used with decompression? coflex (developed by Paradigm Spine), an interlaminar stabilization device implanted after open decompression. Q6. What are the FDA approvals? Superion — PMA P140004 (2015). coflex — PMA P110008 (2012). Both are premarket-approved.
Q7. What happened to X-STOP? It was an early interspinous spacer (Medtronic/Kyphon) that was withdrawn from the U.S. market in 2015; it is no longer implanted. Q8. What is the device HCPCS code? C1821 (interspinous process distraction device, implantable), reported on facility claims for these device-intensive procedures. Q9. Does Medicare cover these procedures? There is no NCD and no active MAC LCD; Medicare adjudicates on medical necessity aligned to each device's FDA indication and generally reimburses well-documented cases. Verify current MAC articles. Q10. Do commercial plans cover them? Stand-alone spacers are broadly experimental/investigational across major national payers. coflex used with decompression is plan-dependent — some allow it with laminectomy, others deem it investigational. Q11. Why do payers deny stand-alone spacers? Largely because the pivotal Superion trial compared it to another spacer (X-STOP) rather than to surgery or conservative care. Q12. What stenosis severity is required? Moderate degenerative LSS for stand-alone Superion; for coflex, stenosis warranting decompression at the affected level(s). Q13. Is spondylolisthesis allowed? Up to Grade 1 (stable) spondylolisthesis is within the indications; greater-than-Grade-1 listhesis or instability is not. Q14. How many levels can be treated? One or two contiguous lumbar levels (L1-L5). Q15. How much conservative care is expected? At least 6 months of non-operative treatment, embedded in both FDA indications. Q16. What is the primary diagnosis code? M48.062 (lumbar spinal stenosis with neurogenic claudication). M48.06 is a non-billable parent and will be rejected. Q17. Are the implants MRI compatible? Both current devices are titanium and MR Conditional; apply the manufacturer's current MRI conditions and have patients disclose the implant. Q18. What is the most common coding error? Coding by device brand instead of by decompression status, or omitting C1821 on the facility claim. Q19. Can prior spine surgery affect candidacy? Yes. Prior fusion or decompressive laminectomy at the index level is an explicit coflex contraindication. Q20. How does this category differ from MILD/PILD? MILD/PILD is a direct decompression that removes ligamentum flavum with no implant (62330/+62331); the spacer category places an implant and works by indirect decompression or with decompression. Q21. What is the strongest single control on this category? Reconciling the operative note against the billed code so device, decompression status, and CPT® pair all agree.
Q22. Where is the device-specific Superion detail? In Guide 02 (Vertiflex / Superion), which carries the full device, indication, and coverage discussion for the stand-alone spacer.
27. Key Takeaways
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- The category splits into without decompression (Superion, 22869/+22870) and with
decompression (coflex, 22867/+22868).
- The operative note's decompression status — not the device brand — selects the CPT® pair;
always include device C1821.
- FDA: Superion PMA (2015), coflex PMA (2012); X-STOP withdrawn 2015.
- Medicare: no NCD, no active LCD; adjudicated on medical necessity to each device's FDA
indication.
- Commercial: stand-alone spacers broadly investigational; coflex-with-decompression is
plan-dependent.
- Primary diagnosis M48.062; document moderate severity, relief in flexion, and up-to-Grade-1
stability.
28. Future Outlook
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The category continues to evolve at both the device and the coverage level. Newer posterior dynamic-stabilization and facet-replacement technologies — for example, the TOPS System, which received FDA premarket approval in 2023 — expand the posterior-stabilization landscape adjacent to interspinous spacers and will bring their own coding and coverage questions. For the established spacers, continued longer-term and comparative-effectiveness evidence, particularly against direct decompression, is the lever most likely to move commercial policies off an investigational posture. Society coverage recommendations and utilization-management guidelines are revised periodically, and the absence of a Medicare LCD could change. The durable operational posture — code from the decompression status, build to the FDA indication, and appeal with device-specific evidence — remains correct regardless of how the category shifts.
29. References
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- U.S. Food & Drug Administration. Superion Interspinous Spacer — PMA P140004; coflex Interlaminar Technology
— PMA P110008 (Summary of Safety and Effectiveness Data). https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm
- American Medical Association. CPT® code set (22867, +22868, 22869, +22870).
https://www.ama-assn.org/practice-management/cpt
- Patel VV, Whang PG, Haley TR, et al. Superion interspinous process spacer for intermittent neurogenic
claudication secondary to moderate lumbar spinal stenosis: two-year results from a randomized controlled FDA-IDE pivotal trial. Spine (Phila Pa 1976). 2015;40(5):275-282. PMID 25494323.
- Nunley PD, Patel VV, Orndorff DG, et al. Five-year durability of stand-alone interspinous process decompression
for lumbar spinal stenosis. Clin Interv Aging. 2017;12:1409-1417. PMID 28919727.
- Davis RJ, Errico TJ, Bae H, Auerbach JD. Decompression and Coflex interlaminar stabilization compared with
decompression and instrumented spinal fusion for spinal stenosis and low-grade degenerative spondylolisthesis: two-year results from the FDA IDE trial. Spine (Phila Pa 1976). 2013;38(18):1529-1539. PMID 23680830.
- North American Spine Society. Coverage recommendations: lumbar interspinous devices with decompression
(2018). https://www.spine.org
- eviCore healthcare. Musculoskeletal / lumbar decompression clinical guidelines (CMM-608).
https://www.evicore.com/provider/clinical-guidelines
- Boston Scientific. Superion Indirect Decompression System — indications and MRI conditionality.
https://www.bostonscientific.com/en-US/medical-specialties/pain-management/mri-conditionality.html
- ICD-10-CM 2026: M48.061 / M48.062 (lumbar spinal stenosis); M43.16 (lumbar spondylolisthesis).
https://www.cms.gov/medicare/coding-billing/icd-10-codes
- GoHealthcare MSK Specialty Procedure Library — Guide 02: Vertiflex / Superion (device-specific detail).
30. Reading Recommendations
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- FDA SSED documents for Superion (P140004) and coflex (P110008) — the authoritative indications
and labeling.
- Patel 2015 (Superion RCT) and Davis 2013 (coflex RCT) — the pivotal trials for each family.
- eviCore CMM-608 and your top commercial plans' interspinous/interlaminar policies — the
controlling coverage language.
- The GoHealthcare Vertiflex guide (Guide 02) for stand-alone spacer device detail.
31. Related GoHealthcare Resources (Internal Links)
Source page 15
- GoHealthcare MSK Specialty Procedure Library — Guide 02: Vertiflex / Superion (device-specific
companion).
- GoHealthcare MSK Specialty Procedure Library — Guide 01: MILD and Guide 03: PILD
(direct-decompression contrast).
- GoHealthcare Prior Authorization Playbook — investigational-denial appeal templates.
- GoHealthcare Revenue Cycle Knowledge Center — device-intensive procedure and ASC packaging
guidance.
32. Recommended Downloads
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- Category coding decision card: 22867 (with decompression) vs. 22869 (without); device C1821.
- FDA-indication-aligned medical-necessity templates for Superion and coflex.
- Operative-note-to-code reconciliation checklist.
- Investigational-denial appeal templates with device-specific evidence citations.
33. Visual Recommendations
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- Decision tree: open decompression performed? — 22867 if yes, 22869 if no.
- Category map: stand-alone (Superion) vs. with-decompression (coflex) vs. legacy (X-STOP).
- Coverage matrix: posture by device and major payer/UM vendor.
- Coding comparison table: 22867/+22868 vs. 22869/+22870 vs. 62330/+62331.
- High-level anatomy illustration of interspinous vs. interlaminar placement.
34. Document History
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Version Date Summary
1.0 2026 Initial publication under GoHealthcare Clinical Procedure Guide Standard v1.0. Category
companion to the Vertiflex guide; reflects the 22867-22870 code family and device code C1821, Superion (PMA P140004) and coflex (PMA P110008) indications, the absence of an active Medicare LCD, and the current commercial-payer landscape.
35. Educational Disclaimer
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This document is part of the GoHealthcare Practice Solutions Knowledge Center and is intended for educational and operational reference purposes only. It is not a physician training manual, procedural technique guide, clinical textbook, or legal advice, and it does not replace physician clinical judgment, payer policy review, or official CMS guidance. It is not a substitute for specialty society procedural training. Coverage policies, coding guidance, and reimbursement requirements change frequently and vary by payer, product, plan, and jurisdiction; they must always be verified against the applicable payer policy and current regulatory sources before clinical or billing decisions are made. CPT® is a registered trademark of the American Medical Association. Product and company names, including Superion® and coflex®, are the property of their respective owners and are referenced for identification only.
Developed by Pinky Maniri
Founder & Chief Executive Officer, GoHealthcare Practice Solutions
National Musculoskeletal Specialty Management Services Organization (MSO)