Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laminectomy to be performed within the next two weeks.Researchers conducted a systematic review of the recent literature, and their review found that the literature demonstrates that decompressive surgery is more effective than land-based exercise in the management of lumbar spinal stenosis. However, given the condition's slowly progressive nature and the potential for known surgical complications, they recommended that a trial of conservative management with land-based exercise be considered prior to consideration of surgical intervention. Researchers recommend surgery for spinal stenosis for patients who do not improve with conservative treatment. Numerous studies have demonstrated the role of surgical decompression in this patient population. The inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability. Current evidence based medical literature indicates that chronic conditions such as degenerative spinal disorders, spinal stenosis or spondylolisthesis without neurologic deficit, and symptomatic implants can all be reasonably managed in an elective fashion during the COVID-19 era. Stable fractures without progressive deformity or neurological compromise, stable pseudoarthrosis without concern for hardware failure, spinal deformity, spinal stenosis without progressive neurological deterioration, and stable proximal junctional kyphosis or other adjacent level degenerative conditions, should all be managed whenever possible with conservative treatment until resources being utilized to combat the COVID-19 pandemic allow.In this case, the patient presented with a history of chronic low back pain with associated left thigh weakness and numbness and tingling into the lower extremities. The patient reported functional limitations in activities of daily living and his ability to work. Recent clinical exam findings did not document a progressive neurologic deficit. There is imaging evidence of multilevel degenerative disc disease and facet arthropathy with multifactorial spinal stenosis at the L3/4 level. The patient has reportedly failed non-operative treatment. The patient was scheduled for an L3/4 laminectomy for a diagnosis of lumbar spinal stenosis and radiculopathy. He canceled the morning of surgery, however, due to lack of a clear understanding of the procedure. He was subsequently scheduled for a spine surgeon visit, with surgery rescheduling apparently in process. The Health Plan has indicated that the patient will be rescheduled as soon as possible after his consult with his spine surgeon. There are no red flag conditions noted in the submitted records, and the patient has been advised to present to the emergency department if he develops new symptoms. Therefore, there is no clinical evidence of progressive neurological deterioration that would support surgical scheduling outside the standard process. During this COVID-19 era, surgical scheduling at the control of the health care system with participation of the spine surgeon is medically indicated to allow for allocation of resources. Under these circumstances, the requested laminectomy to be performed within the next two weeks is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.