Appeal type: Experimental/Investigational
Decision: Overturned


Diagnosis: Lumbar spinal stenosis and neurogenic claudication

Treatment: Percutaneous laminectomy (0275T) 

The insurer denied coverage for percutaneous laminectomy (0275T)

The denial is overturned

According to the clinical documentation provided for review, the treating provider is requesting plan approval for treatment with percutaneous laminectomy (0275T). The patient has the medical diagnosis of moderate to severe lumbar spinal stenosis and neurogenic claudication. The patient has chronic back pain and chronic leg pain. The patient has a magnetic resonance imaging (MRI) scan, which confirmed moderate to severe central canal stenosis at lumbar (L) 4 and 5 levels. The treating provider has appealed this denial and noted that the minimally invasive lumbar decompression (MILD) procedure is approved and has been shown to be effective. The patient was noted to have persistent back pain. The patient had no pain relief after interlaminar injections. On examination, the patient was noted to be obese and have normal gait and pain radiates to the right leg and toe. The evaluation for medical cannabis for chronic pain was performed. The MRI scan of the lumbar, confirmed moderate to severe facet arthropathy, ligamentum flavum hypertrophy, and moderate to severe central canal stenosis at L4 with L5. 

The records establish that the patient has had leg pain and burning for years and he has not improved with nonsurgical care. The records establish that MRI has demonstrated moderate to severe stenosis at L4 and L5. The studies cited establish that MILD procedure is established to be safe and efficacious. 

"Spinal stenosis is the compression of nerve roots by bone or soft tissue secondary to the narrowing of the spinal canal, lateral recesses, or intervertebral foramina. Spinal stenosis may have acquired or congenital origins. Most cases are acquired and caused by hypertrophy of the ligamentum flavum, enlarged osteophytes, degenerative arthritis, disk herniations, and various systemic illnesses. The ligamentum flavum (LF) is a highly specialized elastic ligament that connects the laminae of the spine and fuses them to the facet joint capsules. There are a number of treatment options available for spinal stenosis. Implants and surgical interventions have grown in popularity recently, and a number of these have been shown to have varying efficacy, including the MILD, Vertiflex, Coflex Interlaminar Stabilization, and MinuteMan G3 procedures. MILD is a minimally invasive outpatient procedure to treat spinal stenosis related to hypertrophied ligamentum flavum. The Superion Interspinous Spacer, also known as Vertiflex, is a titanium implant that is delivered percutaneously to relieve back pain caused by lumbar spinal stenosis. The MinuteMan is a minimally invasive, interspinous-interlaminar fusion device planned for the temporary fixation of the thoracic, lumbar, and sacral spine, which eventually results in bony fusion. Based on our review of the available current scientific literature, the novel interventions for symptomatic lumbar spinal stenosis, such as the MILD procedure and the Superion interspinous spacer, generally appear to be safe and effective. There is a possibility in the future that these interventions could disrupt current treatment algorithms for lumbar spinal stenosis." (Kaye, et al., 2021)

"Conclusions: Low back pain (LBP) was alleviated at 2 weeks after lumbar decompression surgery for lumbar disc herniation and lumbar spinal stenosis. The predictors of residual LBP after decompression included more severe LBP at baseline, degenerative scoliosis and the size of Cobb angle." (Oba, et al., 2017)

The requested service is likely to produce a more clinically beneficial outcome to the patient without increased risk. As noted above this procedure is supported by the literature for this clinical scenario.

The carrier's denial of percutaneous laminectomy (0275T) should be overturned.