Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Other/spinal stenosis, lumbar region with neurogenic claudication
Treatment: Back surgery
The health plan denied the requested back surgery as not medically necessary. 
The health plan's determination is upheld.

This is a male with a history of low back and right leg pain. He has had physical therapy, injections and medications without relief. He is a non-smoker. The neurologic exam shows no motor, sensory, or reflex abnormalities. The lumbar magnetic resonance imaging (MRI) shows moderate to marked spinal stenosis at (lumbar) L3-4. The provider has recommended a lumbar fusion at L3-4 with a Minuteman device.
At issue is the medical necessity for the requested health service/treatment of back surgery.

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

No. The procedure is not medically necessary. The patient has spinal stenosis at L (lumbar) 3-4 and has failed conservative therapy. The literature does not support lumbar fusion after decompression without spondylolisthesis and instability. Thomas et al cite, "The addition of fusion to decompression did not result in improved outcomes at 3, 12, or 24-month follow-up. The addition of fusion to decompression provides no advantage to decompression alone for the treatment of patients with neurogenic claudication secondary to lumbar stenosis without spondylolisthesis or deformity".
The medical literature is not completely supportive of Interspinous Processes devices (IPD). Pintauro et al cite "the long-term functionality of these devices is questionable, with radiologic changes and recurrence of symptoms often seen by 2 years following implantation. Next-generation devices do not appear to be subject to the same "bounce back" effect of symptom re-emergence after several years". Fransen et al cite "despite initial satisfactory results, long-term follow up is disappointing, with 80% (percent) poor or average results. The long-term reoperation rate is high (66.6%), increases over time and is higher than after implantation of IPDs (Interspinous Processes devices) for decompression augmentation. Although this technique is simple and safe, its effectiveness seems short-lived. We recommend cautious use and informing patients about the risk of relatively early failure and recurrence". Lastly, Zhong et al cite "Single-leveldevices had higher perioperative 90-day complications, longer operative time, length of stay, higher estimated blood loss compared to laminectomies alone. Similar overall revision and neurologic complication rates were noted compared to laminectomy at last follow-up." Schenck et al cite "IPD (Interspinous Processes devices) implantation is a more expensive alternative to decompressive surgery but has comparable functional outcome during follow-up. The risk of reoperation due to absence of recovery is substantial in the first 2 years after IPD (Interspinous Processes devices) implantation, but if surgery is successful this positive effect remains throughout long-term follow-up. The IPD (Interspinous Processes devices) group had less back pain during long-term follow-up, but the clinical relevance of this finding is debatable. The present study shows that bony decompression remains the gold standard treatment of neurogenic claudication because the reoperation rate during the first years after surgery was higher than IPD (Interspinous Processes devices) group and IPD costs are substantial."