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 [computed 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 upheld.

The patient has a past medical history of spinal stenosis, spondylolisthesis, spondylosis, and hypertension.  Magnetic resonance imaging (MRI) of the lumbar spine revealed multilevel degenerative changes with varying degree of neural canal and central spinal canal stenosis most severe at L (lumbar) 4-5 and L5-S (sacral) 1 again with severe central spinal canal stenosis at those 2 levels similar to the prior study.  There was increased fluid within the bilateral facet joint spaces of L5, again with mild adjacent soft tissue formation surrounding the posterior elements of L5.  At L5-S1 there was grade 1 anterolisthesis of L5 on S1 with mild Modic type II changes endplates, and there was also marginal osteophyte formation.  The flexion and extension x-rays of the lumbar spine revealed no evidence of dynamic instability.  There was grade 1-2 anterolisthesis of L4 on L5 and L5 on S1.  There was most level degenerative disc disease.  The electrodiagnostic studies revealed subacute left L5-S1 radiculopathy with active ongoing axonal loss and chronic right L4-S1 and left L4 radiculopathy, mild in degree electrically.  There was no evidence of neuropathy or myopathy. The patient underwent a telehealth visit.  The patient had a bilateral sacroiliac joint injection and reported 80% (percent) relief 15 minutes after the procedure.  The pain returned shortly after and was present in the same location.  It was present across the low back and buttocks bilaterally.  It remained worse with prolonged standing and sitting progressing as the day went on.  The pain impeded her work and activities of daily living performance, as she was a surgeon and was required to stand for hours at a time.  The patient had been recommended to undergo a minimally invasive option to treat lumbar spine stenosis prior to proceeding with a lumbar fusion.  The patient had undergone lumbar epidural steroid injections, a sacroiliac joint injection, and bilateral sacroiliac joint injection.  The patient had a subjective straight leg raise that was negative, a positive Patrick's test bilaterally, positive Fortin's finger by laterally that was positive, and was unable to do a thigh thrust due to pain.  The patient reported decreased range of motion and mild pain with extension and facet loading.  The treatment plan included a MILD [minimally invasive lumbar decompression]  procedure to the L4-L5 and L5-S1 levels under fluoroscopic guidance for ongoing pain refractory to a caudal epidural steroid injection.

She is not a good candidate. This not the best available treatment. Additional studies are needed.

According to current literature, minimally invasive procedures of the lumbar spine such as the requested Percutaneous Image-Guided Lumbar Decompression are in need of further long-term studies. Going forward, long-term outcome studies and cost-effectiveness studies will be needed to fully assess the benefits of minimally invasive surgery techniques for treating degenerative disease of the lumbar spine.

Therefore, as the current scientific evidence and clinical practice guidelines do not indicate this procedure is not more likely to be beneficial to this patient the requested procedure would not be appropriate.

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 (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar should be upheld.