Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Lumbar Spinal Stenosis, Spondylolisthesis, and Spondylosis.
Treatment:  0275T, percutaneous laminotomy/laminectomy (interlaminar approach) for decompression or neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT [computerized tomography]), single or multiple levels, unilateral or bilateral; lumbar.

The insurer denied coverage for 0275T, percutaneous laminotomy/laminectomy (interlaminar approach) for decompression or neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar.  The denial is overturned.  

The patient has a history of low back pain that is chronic. The patient is status post caudal epidural steroid injection to the midline L (lumbar) 4-L5 with 50% (percent) relief for several weeks. The patient continues to have progressive radiating pain to the buttocks and mid-thigh. The patient stopped physical therapy due to pain. The patient previously had multiple transforaminal epidural steroid injections, lumbar epidural steroid injections, caudal epidural steroid injections, and sacroiliac (SI) joint injections. Examination noted positive Patrick's bilaterally, decreased range of motion with mild pain with facet loading, and positive Fortin finger bilaterally. Diagnoses include spondylolisthesis lumbosacral region, lumbar spondylosis, spinal stenosis lumbar region with neurogenic claudication, SI joint dysfunction bilateral.

"MILD [minimally invasive lumbar decompression] is intended for patients with central stenosis due to LFH (ligamentum flavum hypertrophy); however, bulging discs, foraminal narrowing, and facet hypertrophy or arthrosis were common and actually were associated with higher rates of response than the Encore population as a whole (Table (Table4).4). Further, responder rates for patients with bulging disc and facet hypertrophy were statistically significantly higher than those without these comorbidities. Thus, our data suggest that the mere presence of these comorbidities should not be used as an exclusion." (Staats et al. 2018).     
    
The patient has tried and failed PT (physical therapy), pharmaceutical management, and epidural steroid injections. The patient continues to have pain despite conservative measures. The FDA [Food and Drug Administration] approved minimally invasive lumbar decompression (MILD), and the US (United States) Centers for Medicare and Medicaid Services approved nationwide Medicare coverage of MILD, and the risks are not increased compared to other surgical treatments. Thus, 0275T, percutaneous laminotomy/laminectomy (interlaminar approach) for decompression or neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), single or multiple levels, unilateral or bilateral is considered medically necessary.                                                    

The carrier's denial of 0275T, percutaneous laminotomy/laminectomy (interlaminar approach) for decompression or neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar should be overturned.