Coverage Decisions for Medical Technologies & Procedures

X-STOP Interspinous Process Device

Coverage decision

The X-STOP® interspinous process device is not covered at this time. L&I reviewed the scientific literature addressing this device and determined there is not sufficient evidence of safety and efficacy.

Background

X-STOP® is an implantable device intended to limit motion of vertebrae (bones in the spine). Reduction of vertebral motion may prevent pain caused by compression of blood vessels and nerves in or near the spine. X-STOP is intended for use in persons 50 years of age and older with moderate impairment from a condition called neurogenic intermittent claudication (NIC).

Potential benefits of the device include:

• Less invasive than some surgical alternatives,
• Reversible procedure, and
• Implantation can be completed without general anesthetic for most patients.

L&I reviewed the available scientific literature and determined there is not sufficient evidence showing short-term or long-term safety and effectiveness for the intended use. L&I will review new scientific information relevant to this policy as it becomes available.

Billing codes

Specific CPT™ billing codes for X-STOP became effective on January 1, 2007. These codes are not paid by the insurer.

Code	Description
CPT™ 0171T	Single level insertion
CPT™ 0172T	Additional level insertions
HCPCS C1821	Interspinous process distraction device (implantable)

For more information:
WAC 296-20-02704 - What criteria does the director or director's designee use to make medical coverage decisions?
WAC 296-20-02850 - When may L&I cover controversial, obsolete, investigational or experimental treatment?

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