LCD/NCD Portal

L28775

 

INTERSPINOUS PROCESS DECOMPRESSION

 

 

10/01/2010

 

 

Indications and Limitations of Coverage and/or Medical Necessity

Indications

• Medicare will consider Interspinous Process Decompression medically reasonable and necessary for patients who meet ALL of the following criteria:

o Aged 50 or older suffering from (intermittent neurogenic claudication) secondary to a confirmed diagnosis of lumbar spinal stenosis.

o With moderately impaired physical function who experience relief in flexion from their symptoms of leg/buttock/groin pain, with or without back pain.

o Patients who have undergone at least 6 months of non-operative treatment including:

 Medications.

 Corticosteroid injection therapy.

 Rest or restricted activity.

 Devices designed to help stabilize the spine such as back braces/corsets.

 Physical therapy/exercises to help stabilize the spine that help to build endurance and increase flexibility.

• The diagnosis of lumbar stenosis must be confirmed by radiological evidence i.e. report resulting from a:

o  CT scan.

Or

o MRI.

Or

o Myelogram.

• The medical record contains documentation that fully supports the medical necessity of the procedure performed including but is not limited:

o Relevant medical history.

o Physical examination.

o Results of pertinent diagnostic tests or procedures.

 

 

Limitations

• Interspinous Process Decompression will NOT be considered medically reasonable and necessary with ANY of the following conditions:

o Allergic to titanium or titanium alloy.

o Spinal anatomy or disease that would prevent implant of the device or cause the device to be unstable in situ, such as:

 Significant instability of the lumbar spine.

 Isthmic spondylolisthesis or degenerative spondylolisthesis greater than grade 1.0 (on a scale of 1 to 4).

 An ankylosed segment at the affected level(s).

 Acute fracture of the spinous process or pars interarticularis.

o Significant scoliosis (Cobb angle greater than 25 degrees).

o Cauda equina syndrome defined as neural compression causing neurogenic bowel or bladder dysfunction.

o Diagnosis of severe osteoporosis, defined as bone mineral density (from DEXA scan or some comparable study) in the spine or hip that is more than 2.5 SD below the mean of adult normals in the presence of one or more fragility fractures.

o Active systemic infection or infection localized at the site of implantation.

o Body mass index (BMI) > 40kg/m².

Utilization Guidelines

• It is expected that these services would be performed as indicated by current medical literature and/or standards of practice.

o This procedure may be performed at one or TWO spinal levels.

 (When services are performed in excess of established parameters, they may be subject to review for medical necessity.)

• It is expected that the patient has NOT previously received a laminotomy or laminectomy at the same level of the spine as the Interspinous Process Decompression.

• Services performed on patients who have received another spinal procedure such as ANY spinal instrumentation (CPT codes 22840-22849) and laminectomy or laminotomy (CPT codes 63001-63048) MAY BE SUBJECT TO DENIAL.

 

 

Coding Information

 

CPT/HCPCS Codes

 

0171T INSERTION OF POSTERIOR SPINOUS PROCESS DISTRACTION DEVICE (INCLUDING NECESSARY REMOVAL OF BONE OR LIGAMENT FOR INSERTION AND IMAGING GUIDANCE), LUMBAR; SINGLE LEVEL

0172T INSERTION OF POSTERIOR SPINOUS PROCESS DISTRACTION DEVICE (INCLUDING NECESSARY REMOVAL OF BONE OR LIGAMENT FOR INSERTION AND IMAGING GUIDANCE), LUMBAR; EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

 

 

ICD-9 Codes that Support Medical Necessity

 

724.03 SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION

 

 

Treatment Logic

• Interspinous Process Decompression is a less invasive surgical procedure in which a titanium metal implant is placed between the spinous processes of the symptomatic lumbar disc levels.

• The implant may be placed at two levels if necessary.

• It is performed as an alternative to laminectomy for patients diagnosed with lumbar spinal stenosis who exhibit symptoms of intermittent neurogenic claudication and are able to relieve their symptoms when bending forward or when the spine is in a flexed position such as when sitting.

• The implant is designed to limit pathologic extension of the spinal segments and maintain them in a neutral or slightly flexed position which may allow patients to resume their normal posture rather than flex the entire spine to gain symptom relief.

• Interspinous Process Decompression is performed in the operating room under local, spinal or general anesthesia.

• It is done as either an inpatient or outpatient procedure depending upon the number of levels performed and the associated co-morbidities.

 

 

Sources of Information and Basis for Decision

 

California Technology Assessment Forum (2006) An interspinous process distractor (X STOP) for the treatment of spinal stenosis of the lumbar spine -A technology assessment retrieved from http://www.ctaf.org/ on February 9, 2007.

 

Department of Health and Human Services (2005) X STOP® Interspinous Process Decompression System –P040001 retrieved from http://www.fda.gov/cdrh/pdf4/p040001.html. Retrieved February 9, 2007.

 

FCSO LCD 29204, Interspinous Process Decompression, 10/01/2010. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Kondrashov DG, Hannibal M, Hsu KY, Zucherman, JF. (2006) Interspinous process decompression with the X-STOP device for lumbar spinal stenosis. Journal of Spinal Disorders & Techniques 2006; 19 (5):323-327.

 

Murphy DR, Hurwitz EL, Gregory AA, Clary R.(2006) A non-surgical approach to the management of lumbar spinal stenosis; a prospective observational cohort study. BMC Musculoskelet Disord. 2006; 7:16.

 

Richards JC, Majumdar S, Lindsey DP, Beaupre GS, Yerby SA. (2005) The treatment mechanism of an interspinous process implant for lumbar neurogenic intermittent claudication. Spine. Apr 1 2005; 30(7): 744-749.

 

Sagun K, Scott A, Yerby SA, Katz JN. (2006) Methodological approaches to developing criteria for improvement in lumbar spinal stenosis surgery. Spine 2006; 31: 1276-1280.

 

Siddiqui M, Karadimas E, Nicol M, Smith FW, Wardlaw D. (2006) Influence of X Stop on neural foramina and spinal canal area in spinal stenosis. Spine 2006; 31(25): 2958-2962.

 

Wiseman CM, Lindsey DP, Fredrick AD, Yerby, SA. (2005) The effect of an interspinous process implant on facet loading during extension. Spine 2005; 30 (8): 903-907.

 

Zucherman JF, Simons P, Timothy J. (2005) X STOP Interspinous implant for lumbar spinal decompression. Brussels International Spine Symposium November 18-19, 2005.

 

Zucherman JF, Hsu KY, Hartjen CA, et al. (2006) A multicenter, prospective, randomized trial evaluating the X STOP interspinous process decompression system for the treatment of neurogenic intermittent claudication. Spine 2006; 30(12): 1351-1358.

 

 

AMA CPT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

 

CMS LCD INTERSPINOUS PROCESS DECOMPRESSION