Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neurogenic Claudication due to Lumbar Stenosis

Treatment: Percutaneous laminotomy/laminectomy for decompression of neural elements under image guided computed tomography (CT), cervical or thoracic (partial removal of bone with release of spinal cord or spinals)

The insurer denied coverage for pre-service request for percutaneous laminotomy/laminectomy for decompression of neural elements under image guided CT, cervical or thoracic (partial removal of bone with release of spinal cord or spinals)

The denial is upheld

This patient is a male with a history of clotting disorder, arthritis, gastroesophageal reflux disease (GERD), gout, hypertension, and sleep apnea.  The patient presented with lower back pain, lower extremity symptoms and neurogenic claudication.  The patient had a 4-level disc arthroplasty 2 weeks prior to arrival.  The patient's pain was rated at a level of 2 out of 10.  On a good day, the patient reported that his pain is 2 out of 10 and on a bad day, the pain is at 10 out of 10.  The patient reported that his back pain radiates into the bilateral lower extremities in a posterolateral fashion.  The patient's magnetic resonance imaging (MRI) of the lumbar spine revealed a diffuse disc bulge and facet with degenerative changes at the L4-L5 level.  There were also bilateral joint facet diffusions resulting in moderate spinal canal narrowing.  The patient would like to try conservative management before pursuing surgery and would like the minimally invasive lumbar decompression (MILD) procedure.

As per literature review, the MILD Percutaneous Image-Guided Lumbar Decompression: A Medicare Claims Study (NCT03072927) is an on-going clinical trial.1 Depending on the outcome of this trial; the Centers for Medicare & Medicaid Services (CMS) may or may not decide to offer coverage.  In this case, this patient is not enrolled in a clinical trial at this time.
 
Jain et al. (2020) summarizes the indications and contraindications of the minimally invasive lumbar decompression (MILD) procedure. Jain et al. (2020) states: "To summarize, all of the following inclusion criteria must be met for the patient to be a candidate for the mild procedure: Symptomatic LSS (i.e., presence of neurogenic claudication); Confirmation of stenosis on imaging; LFH (LF >=2.5 mm)...he following contraindications must be accounted for before the procedure is performed on the patient: Absolute contraindications: Prior spine surgery at the intended level of treatment."

In this case, the physician's note states: "The patient is 2 weeks [status post (s/p)] 4 level disc arthroplasty." This patient's prior spine surgery at the intended level of treatment is an absolute contraindication to this requested MILD procedure. Therefore, this procedure is not considered medically necessary for this patient. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the pre-service request for percutaneous laminotomy/laminectomy for decompression of neural elements under image guided CT, cervical or thoracic (partial removal of bone with release of spinal cord or spinals) should be upheld. The medical necessity is not substantiated.