Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested authorization and coverage for endoscopic lumbar discectomy / foraminotomy / dorsal endoscopic rhizotomy at L4-L5 and L5-S1 level under fluoroscopic guidance for treatment of back and leg pain.   Findings:  Three physician reviewers found that the patient is a 60-year-old female with back and leg pain. Her provider noted a long history of back problems, with a prior fusion for scoliosis from T3-T10, and a later extension T10-L4.  The medical records noted that the patients back pain had increased over the years, significantly for six months, with left lower extremity pain, as well as neurogenic claudication. Conservative measures were unsuccessful.  On examination, motion was limited in the back. Straight leg raising was negative bilaterally. Strength was intact.  X-rays were described as showing grade 2 spondylolisthesis at L4-5, with disc degeneration, severe at L4-5, and moderate at L5-S1. An MRI was described as showing severe spinal stenosis at L4-5. An MRI of the lumbar spine was then performed.  At L4-5, there was narrowing.  At L5-S1, there was right paracentral and foraminal protrusion, without canal or foraminal stenosis. In an addendum, this was described as also involving the left foramen.  Approximately two months later, the provider noted that the patient had been seen for over five years for thoracic and lumbar pain, with recent increased lumbar spine problems, not controllable with medications, epidural or nerve block injections. The medical records noted that prior treatments included physical therapy, medications, and a TENS unit.  On examination, there was limited motion and tenderness in the lumbar spine, decreased sensation, 1+ reflex at the knees and ankles, and good strength. The patients diagnoses included bilateral foraminal stenosis L4-L5, with disc protrusion and spondylolisthesis, and at L5-S1, disc bulge.  The patient has requested authorization and coverage for endoscopic lumbar discectomy / foraminotomy / dorsal endoscopic rhizotomy at L4-L5 and L5-S1 level under fluoroscopic guidance.  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient.  At this time, the superior efficacy of the requested services has not been established. In the attempt to avoid the problems associated with open surgical procedures, there has been interest in more minimal approaches, such as endoscopic procedures and microdiscectomy, and different techniques, such as the axial lumbar interbody fusion. Encouraging early results have been reported for endoscopic procedures, but the need for randomized, controlled studies has also been noted. A similar situation exists for the axial approach, with some encouraging reports in the literature, but also reports of complications, pointing to the need for further study.  In this patients case, the requested endoscopic lumbar discectomy / foraminotomy / dorsal endoscopic rhizotomy at L4-L5 and L5-S1 level under fluoroscopic guidance is not likely to be more efficacious than other available treatment options.