Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain

Treatment: Outpatient percutaneous image-guided lumbar decompression procedure

The insurer denied coverage for outpatient percutaneous image-guided lumbar decompression procedure

The denial is upheld

Reviewer Number (#) 2:

This is an adult patient with a chief complaint of lumbar pain. The patient is having worsening low back and buttocks pain with intermittent pain down the legs. The patient has tried and failed physical therapy (PT) and oral medications. Medications prescribed include ibuprofen and oxycodone. Epidural injections, medial branch blocks (MBB), and radiofrequency ablation (RFA) have provided minimal relief. Physical exam reveals bilateral paraspinal musculature tenderness to palpation, and positive bilateral facet loading tests. Magnetic resonance imaging (MRI) demonstrates multilevel spondylosis and severe facet arthrosis with spinal and neural foraminal stenosis resulting in descending and exiting nerve root impingement at lumbar (L) 2-L5. The physician recommended the minimally invasive lumbar decompression (MILD) procedure.

The MILD (minimally invasive lumbar decompression) procedure is generally described as a noninvasive procedure using specially designed instruments to percutaneously remove a portion of the lamina and debulk the ligamentum flavum. The procedure is performed under x-ray guidance (For example (e.g.), fluoroscopic, computed tomography) with contrast media to identify and monitor the compressed area via epidurogram. This procedure is indicated for central stenosis due to ligamentum flavum hypertrophy only, without the capability of addressing nerve root compression, disc herniation, or facet joint hypertrophy should it be required. Systematic review found that current evidence does not support the routine use of minimally invasive surgery for cervical or lumbar discectomy and the benefits to long term health outcomes are unknown. Minimally invasive surgery has no clinically significant advantage in terms of short- or long-term measures of pain or function. Open discectomies are already performed through relatively small incisions, so it is not surprising to find that outcomes are no better with minimally invasive discectomies. UpToDate notes that less invasive decompression procedures, such as the MILD procedure, appear in observational studies to have lower complication rates than traditional surgical techniques. However, it is unclear if these newer procedures offer benefit in terms of improved symptoms and function or fewer complications in routine practice compared with standard decompression with laminectomy. The North American Spine Society makes no specific recommendations on percutaneous image-guided lumbar decompression. 

In summary, the patient has chronic lumbar back and leg pain with lumbar spinal stenosis, severe multilevel facet joint arthrosis, multiple lumbar disc herniations, and multiple lumbar nerve root impingements. The patient has failed conservative treatment including medication, PT, and epidural steroid injections. The physician is recommending the MILD procedure. The procedure does not have approval from regulatory bodies for routine use. This patient's severe facet joint arthrosis, multiple disc herniations, and nerve root compressions would not be addressed by this procedure. The requested procedure is not considered standard of care in the general medical community, as there are significant risks and limitations with this procedure, and it is not found to be more effective than that of a traditional open discectomy. The denial should be upheld.

In summary, the denial of an outpatient percutaneous image-guided lumbar decompression procedure and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.