Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Tarlov Cyst Disease (TCD)

Treatment: Sacral laminar reconstructive surgery/spinal surgery (CPT code 64999)

The insurer denied coverage for sacral laminar reconstructive surgery/spinal surgery (CPT code 64999).  The denial was upheld.

Reviewer #1

This patient is a female who reports for the past three years a history of coccygodynia, bladder and bowel dysfunction, inguinal pain, dyspareunia, numbness of the dorsal part of the right foot, tinnitus, pressure headaches with nausea and dizziness, and buttock pain that radiates to her right hip.  While she continues to work, these symptoms have affected her activities of daily living.  She has gained 40 pounds and suffers from depression.  Her past medical history includes migraines, vertigo, depression, Raynaud's syndrome, endometriosis, hysterectomy (2014), and pelvic prolapse.  According to the office note from a provider the patient has decreased right plantar flexion and toe walking, and there is decreased sensation in the left posterior and medial thigh.  According to another provider the neurologic exam was normal.  The pelvic magnetic resonance imaging is significant for a smoothly marginated central canal cystic focus at S2 and S3 levels stable from a previous exam.  Appearance is most typical for Tarlov cyst.  There is surrounding smooth bony remodeling, but no bone marrow edema or extraosseous abnormality.  There is no evidence of acute fracture in the region of the sacrum or coccyx.  A cystic focus of the right adnexal region was likely related to the right ovary, measuring 3.5. cm.

Sacral laminar reconstructive surgery is indicated when there is documented advanced erosion or destruction of the sacrum.  Here there is no documented growth of the cyst and no documented bony compromise of the sacrum.  Most Tarlov cyst are asymptomatic, and unless growth is demonstrated, it is unlikely to become symptomatic.  Compared to the previous MRI done 1-year prior, there is no growth of the cyst.  While some of the patient's urinary symptoms could correlate with the presence of nerve root compression, in the absence of a urologic evaluation, this is hard to assess, especially since many of her symptoms such as headaches and vertigo are not explained by the Tarlov cyst.

According to Burke, et al. (2016), "the data suggest that patients with symptomatic Tarlov cysts [TCs] may benefit from open microsurgical treatment.  Although outcomes seem related to patient age, duration of symptoms, and extent of disease demonstrated on imaging, further study is warranted and underway".  Per Yang, et al. (2018), "We report on the growth of TCs, which is consistent with a widely-held theory that hydrostatic and pulsatile forces of cerebral spinal fluid [CSF] along with a ball-valve phenomenon allow for continuous dilation of TCs."  Additionally, according to Baker, et al. (2018), "Patients with symptomatic sacral Tarlov cysts frequently report pain and neuropathy related to the lower back, pelvis and urogenital system.  As compared to the general population, urinary urgency and urodynamic findings associated with urgency were more frequent in our patient sample.  These findings suggest that Tarlov cysts may have a clinically significant impact on urogenital function."  Furthermore per Lim, et al. (2019), "The increased prevalence of Tarlov cysts is likely not the etiology of pudendal neuralgia, yet both could be due to similar pathogenesis from part of a focal or generalized condition."

The patient is not a good candidate for the sacral laminar reconstructive surgery/spinal surgery.  She does not have any evidence that the Tarlov cyst is responsible for her symptoms and signs, and she does not have evidence that the Tarlov cyst is expanding and significantly compromising the sacrum.

The carrier's denial of coverage for sacral laminar reconstructive surgery/spinal surgery (CPT code 64999) should be upheld.