Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested left synovial cyst excision at L3-4, L3-5 partial laminectomy/foraminotomies (Coflex implant) for treatment of the enrollees lumbar degenerative disc disease at L3-4 and L4-5.  Findings: Two physician reviewers found that the request for left synovial cyst excision at L3-4, L3-5 partial laminectomy/foraminotomies (Coflex implant) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Kumar and colleagues performed a literature review to assess whether additional implantation of Coflex following spinal decompression provided better clinical outcomes compared to decompression alone for symptomatic lumbar spinal stenosis (LSS) and to determine whether improvement in clinical outcomes correlated with changes in the radiological indices studied. The authors concluded that Additional Coflex implantation after spinal decompression in symptomatic lumbar spinal stenosis offered better clinical outcomes that decompression alone in the short term. In addition, Musacchio and colleagues concluded that decompression and interlaminar stabilization with Coflex was a viable alternative to traditional decompression and fusion in the treatment with of patients with moderate to severe stenosis at one or two lumbar levels. Moreover, Davis and colleagues reported that the Coflex interlaminar stabilization is a safe and efficacious alternative, with certain advantages compared with lumbar spinal fusion in the treatment of spinal stenosis and low-grade spondylolisthesis. Thus, the evidence based peer-reviewed literature support the use of Coflex interlaminar stabilization with decompression as a safe and efficacious alternative to decompression and/or lumbar fusion for the treatment of lumbar spinal stenosis and low-grade spondylolisthesis. In this case, the patient presents with persistent and worsening low back pain radiating into the lower extremities. She had symptoms of neurogenic claudication with associated significant functional limitations. Clinical exam findings have evidenced lower extremity weakness consistent with imaging evidence of moderate to severe spinal stenosis at the L3-4 and L4-5 levels, a large synovial cyst at L3-4 on the left, and grade 1 spondylolisthesis at the L3/4 level. In addition, she had failed physical therapy, injections, medication, and activity modification. Therefore, the requested surgery has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.