Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p(status post) Motor vehicle accident. 
Treatment: Lumbar Laminectomy. 

The insurer denied the Lumbar Laminectomy. 
The denial is upheld. 

The patient is a male. The patient was evaluated after motor vehicle accident. The patient has been scheduled for an L3-S1 (third lumbar spine vertebra-first sacral vertebra) laminectomy and possible diskectomy. The patient has complaints of neck pain with radiation into the upper extremity. 

The patient's MRI (magnetic resonance imaging) of the lumbar spine shows Moderate flattening of the thecal sac and L3-4 (third lumbar spine vertebra-fourth lumbar spine vertebra) with an extruded disc into the left posterior lateral region.  This encroaches upon the left L3 (third lumbar spine vertebra) nerve root.  The L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) level shows right L5 (fifth lumbar spine vertebra) lateral recess stenosis with some interaction of the right L5 (fifth lumbar spine vertebra) nerve root.  It causes mild flattening of the thecal sac.  At L5-S1 (fifth lumbar spine vertebra-first sacral vertebra) there is a left paracentral disc extrusion which contacts the left S1 (first sacral vertebra) nerve root. 

The patient had treatment with 8-10 physical therapy sessions, and there is no history of injection therapy. 

The patient presented with complaints of low back pain with radiation into the bilateral lower extremities with left foot numbness.  The physical exam shows moderately decreased lumbar range of motion.  The neurologic exam shows 5/5 strength in the lower extremities with normal lower extremity sensation and reflexes.  There is positive straight leg raise for low back pain on the right and on the left.  There is no radicular pain with straight leg raise.  The patient's symptoms are aggravated by sitting.  Patient had previous surgery with anterior cervical diskectomy and fusion of C5-C7 (fifth cervical spine vertebra-seventh cervical spine vertebra). 

The patient's conservative care has included medications including oxycodone, ibuprofen and gabapentin as well as physical therapy.  The radiologist read the MRI (magnetic resonance imaging) report as mild stenosis.  This is a review for the surgery for the lumbar spine. 

No, the requested lumbar laminectomy is not medically necessary. 

The medical necessity for this treatment has not been clearly supported by all the medical evidence.  In this case, the patient does not have symptoms of neurogenic claudication, but states that the symptoms are worse with sitting.  The patient has primarily back pain symptoms with a normal neurologic exam and negative straight leg raise for radiculopathy.  The straight leg raise only provided low back pain complaints.  The MRI (magnetic resonance imaging) does not show moderate or severe stenosis corresponding with the symptoms.  Given all this clinical information, the medical necessity for surgery for the lumbar laminectomy would not be supported by the treatment guidelines.  Neurogenic claudication is not present on the current evaluations.  Furthermore, there is no evidence of spondylolisthesis with neurogenic claudication that would require this surgical procedure. 

The medical necessity for the surgery has not been established.  The patient does not have clinical findings and symptoms consistent with neurogenic claudication that would support the need for laminectomy.  Furthermore, the MRI (magnetic resonance imaging) does not show critical stenosis.  Given the lack of these findings, the medical necessity for the lumbar laminectomy cannot be supported.