Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/spinal stenosis..
Treatment: Lumbar decompression surgery.
The insurer denied lumbar decompression surgery.
The denial is upheld. 

The patient is a male with a history of neurogenic claudication due to spinal stenosis. A magnetic resonance imaging (MRI) of the lumbar spine,  revealed multilevel disc osteophyte complex and central stenosis from thoracic (T)12-lumbar (L)1 to L4-5. An electromyography (EMG) was reviewed and revealed radiculopathy. An interspinal spacer implant targeting the L4-5 level was discussed as a treatment option. X-rays of the lumbar spine revealed multilevel spondylosis.
At issue is the medical necessity of Lumbar decompression surgery.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Lumbar decompression surgery is not medically necessary for this patient.
In 2018, the North American Spine Society (NASS) published specific coverage policy recommendations on the lumbar interspinous device without fusion and with decompression. The NASS recommended that: "Stabilization with an interspinous device without fusion in conjunction with laminectomy may be indicated as an alternative to lumbar fusion for degenerative lumbar stenosis with or without low-grade spondylolisthesis (less than or equal to 3 mm of anterolisthesis on a lateral radiograph) with qualifying criteria when appropriate: 1) Significant mechanical back pain is present (in addition to those symptoms associated with neural compression) that is felt unlikely to improve with decompression alone. Documentation should indicate that this type of back pain is present at rest and/or with movement while standing and does not have characteristics consistent with neurogenic claudication. 2) A lumbar fusion is indicated post-decompression for a diagnosis of lumbar stenosis with a Grade 1 degenerative spondylolisthesis as recommended in the NASS Coverage Recommendations for Lumbar Fusion. 3) A lumbar laminectomy is indicated as recommended in the NASS Coverage Recommendations for Lumbar Laminectomy. 4) Previous lumbar fusion has not been performed at an adjacent segment. 5) Previous decompression has been performed at the intended operative segment."
For individuals who have severe spinal stenosis and grade 1 spondylolisthesis or instability who have failed conservative therapy who receive an interlaminar spacer with spinal decompression surgery, clinical input is not universally supportive of a clinically meaningful improvement in net health outcome. While some respondents considered the shorter recovery time and lower complication rate to be an advantage compared to fusion, others noted an increase in complications and the need for additional surgery. For individuals who have spinal stenosis and no spondylolisthesis or instability who receive an interlaminar spacer with spinal decompression surgery, clinical input is not generally supportive of a clinically meaningful improvement in net health outcomes, with clinical experts noting an increase in complications and need for additional surgery compared to laminectomy alone. Overall, the use of interspinous or interlaminar distraction devices (spacers) as an alternative to spinal decompression has shown high failure and complication rates.
Therefore, the requested health service/treatment of Lumbar decompression surgery is not medically necessary.