Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain

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

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

The denial is upheld 

Reviewer #1:

This is a patient with a diagnosis of lumbar spinal stenosis. The patient complains of ongoing low back pain that became acutely worse after being hospitalized. The patient's pain is rated at 10 out of 10 (10/10), with radiating pain through posterior lateral thighs through lower legs and into feet. Severe back pain with standing to walk with weakness and heaviness in the legs. The patient has been treated in the past with an interlaminar epidural steroid injections (ESI). Medications prescribed include clonazepam, celecoxib, hydroxyzine, baclofen, cyclobenzaprine, and oxycodone-acetaminophen. Physical exam notes lumbar-sacral spine tenderness to palpation, sacroiliac (SI) joint tenderness, positive straight leg raising test bilaterally, and severe lumbar facet tenderness. Magnetic resonance imaging (MRI) shows multilevel anterior endplate osteophyte formations, status post L (lumbar) 5 wedge compression fracture, and a new L4 superior endplate compression fracture. Ligamentum flavum hypertrophy contributes to moderate spinal canal effacement at L4-L5. Moderate bilateral facet arthrosis is also noted at L4-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 (e.g., fluoroscopic, computed tomography) with contrast media to identify and monitor the compressed area via epidurogram. This procedure is indicated for central stenosis 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. 

The patient has chronic back and leg pain with moderate spinal stenosis and moderate bilateral facet joint arthrosis, who has failed conservative treatment including medication, physical therapy (PT), and epidural steroid injections. The physician is recommending the MILD procedure.

In summary, the denial of 0275T; percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g. fluoroscopic, computed tomography [CT]), single or multiple levels, unilateral or bilateral; lumbar 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 substantially increased over standard treatments.