Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Spinal Stenosis
Treatment: Back surgery (percutaneous or endoscopic spinal decompression and fusion)
The insurer is denied coverage for back surgery (percutaneous or endoscopic spinal
decompression and fusion).
The denial is upheld. 

This is a male patient who underwent a decompressive lumbar laminectomy at L2-L3, L3-L4, and L4-L5 with subsequent fusion with no need to remove the facets at L2-L3 to decompress the sac with subsequent fusion at L2-L3 and 60-degree fusion at L2-L3 using fluoroscopy, microscopy and neuromonitoring.

Yong Ahn states, "The various endoscopic spine surgery techniques should be appropriately conducted according to the disease entities, level, and zone of pathologies. Although the current level of evidence is relatively low and the relevance of the technique is controversial, recent clinical results and the critical concept are promising. Development in optics, instruments, and approach will improve its safety and reduce technical complexity. In the meantime, high-quality clinical studies, including randomized trials and meta-analyses, are due for publication. Eventually, endoscopic spine surgery is expected to become the golden standard for spinal surgery." (1)

Chung, et al states, "Current data suggests that spinal endoscopy may be non-inferior to other minimally invasive spinal surgical [MISS] or open techniques in specific surgical settings. Specifically, several randomized-controlled trials and meta-analyses to date have demonstrated equivalent outcomes in patients undergoing spinal endoscopy for the treatment of lumbar stenosis, lumbar disc herniations, and cervical radiculopathy when compared to the use of more conventional MISS techniques. With growing enthusiasm for spinal endoscopy, many variations of surgical techniques have now been described for the treatment of these aforementioned pathologies. Furthermore, there has been a rapid expansion in recent years in the proposed surgical indications for spinal endoscopy. Given the infancy of these technical variations and more novel surgical applications, supporting literature is, in many cases, still limited to a few case series at best. While early data appears to support the efficacy of spinal endoscopy in these expanded settings, it is crucial to remember that our patients' needs must always come first. Consequently, until higher quality evidence emerges, it is absolutely essential to emphasize that careful and slow incorporation of only the most clinically validated
techniques into one's surgical armamentarium is a must, particularly in the early stages of adoption."(2)

The use of percutaneous or endoscopic surgery does not require Food and Drug Administration (FDA) approval.

The patient is not a good candidate for the surgery performed.

Percutaneous or endoscopic surgery is not the standard of care. In a Cochrane review, they concluded that "MID (minimally invasive discectomy) may be inferior in terms of relief of leg pain, LBP (low back pain) and re-hospitalization; however, differences in pain relief appeared to be small and may not be clinically important. Potential advantages of MID are lower risk of surgical site and other infections. MID may be associated with shorter hospital stay but the evidence was inconsistent. Given these potential advantages, more research is needed to define appropriate indications for MID as an alternative to standard MD/OD (Microdiscectomy or open discectomy)."

The requested service is not likely to be more beneficial than other standard treatments. At the time of surgery, percutaneous or endoscopic decompression and fusion has limited studies that show it is as at least as effective or more effective than a standard decompression and fusion for lumbar stenosis.

The carrier's denial of coverage for back surgery (percutaneous or endoscopic spinal
decompression and fusion) should be upheld.