CPT 22867 · Interspinous Device · AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices
Vertiflex — Interspinous Process Decompression (1st level) at AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices.
How AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices approaches CPT 22867 (Vertiflex — Interspinous Process Decompression (1st level)) for prior-authorization review: at last review on 2026-05-06, the policy covers this code with prior authorization required.
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eviCore CMM-608Criteria summary
High-level themes from the AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices policy of record for CPT 22867. Verbatim policy text and per-criterion analysis are available after sign-in.
- At least 24 weeks of conservative care typically required.
- Imaging concordance documentation required.
Source: eviCore CMM-608 — Interspinous Decompression (Vertiflex; AC Family / Keystone First)
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