Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Lumbar decompression
The insurer denied coverage for lumbar decompression.
The denial is upheld.

This case involves an adult female seeking authorization for minimally invasive lumbar decompression (MILD). The patient was diagnosed with lumbar spinal stenosis with neurogenic claudication. She was seen for an evaluation related to low back pain with radiating symptoms into the bilateral buttocks. The patient rated her pain 7 out of 10. Her pain was worsened with standing and ambulating. She recently underwent successful right hip replacement and approximately 4 weeks of physical therapy. She continued to participate in home exercises. Pain limited her ability to cook and clean for more than short periods of time. She stated that her pain was worsening. The physical exam findings of the patient noted mild to moderate tenderness to palpation of the right paraspinous region of the lumbar spine. There was mild left lumbar paraspinous region tenderness. There was moderate sacroiliac joint tenderness. There was positive bilateral flexion abduction external rotation (FABER) testing. There was positive bilateral thigh compression test. The patient had 5 out of 5 strength in the bilateral lower extremities. An order was placed for bilateral sacroiliac joint injections. Magnetic resonance imaging (MRI) of the patient's lumbar spine revealed at lumbar (L) 3-4, moderate left greater than right facet joint ligamentum flavum hypertrophy. There was moderate to severe broad-based posterior disc osteophyte complex with right greater than left transforaminal extension. There was severe right and mild to moderate left neuroforaminal stenosis that was unchanged. There was severe right lateral recess stenosis and moderate to severe central canal stenosis that was unchanged. At L4-5, there was moderate to severe bilateral facet hypertrophy. There was grade 1 anterolisthesis. There was mild posterior disc bulge. There was severe right lateral recess stenosis and moderate central canal stenosis that was unchanged. There was severe right neuroforaminal stenosis that was unchanged.

Per the cited literature, the MILD tool kit initially received marketing clearance from the Food and Drug Administration (FDA), with intended use as a set of specialized surgical instruments. In contrast to surgical decompression, the MILD procedure is a percutaneous decompressive procedure performed solely under fluoroscopic guidance (e.g. ["for example"], without endoscopic or microscopic visualization of the work area). This procedure is indicated for central stenosis only, without the capability of addressing nerve root compression or disc herniation, should it be required. Due to the unknown impact of these limitations on health outcomes, randomized controlled studies in appropriate patients are needed to compare this new procedure with established alternatives. In this case, the patient was diagnosed with lumbar spinal stenosis with neurogenic claudication. The notes did not identify that the patient had evidence of symptomatic stenosis at the requested levels with associated pain in a particular dermatome, decreased sensation, decreased strength, or loss of reflexes. The documentation also did not detail what specific nonoperative treatment the patient had directed towards the lumbar spine. While literature does support the requested procedure for spinal stenosis, there is a lack of exam findings noting symptoms consistent with the requested levels and there was a lack of documentation of failed conservative care to support proceeding with surgical intervention. Lower levels of care including active rehabilitation are recommended for this patient.

This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.

The carrier's denial of coverage for lumbar decompression should be upheld.