Appeal type: Experimental/Investigational
Decision: Upheld

REVIEWER 3

Diagnosis: lumbar spinal stenosis (LSS)

Treatment: MILD (minimally invasive lumbar decompression) procedure

The insurer denied coverage for MILD (minimally invasive lumbar decompression) procedure

The denial is upheld

The patient has lumbar spinal stenosis (LSS) and has chosen to move forward with the minimally invasive lumbar procedure to be performed at lumbar (L) 3-L4. The patient has had decompression (MILD) diagnostic imaging including magnetic resonance imaging (MRI). The current imaging supports lumbar spinal stenosis with hypertrophic ligamentum flavum, and the patient has radiologically confirmed lumbar spinal stenosis with hypertrophic ligamentum flavum at L3- L4.

The peer-reviewed literature does not support a result of improvement in health outcomes. Minimally invasive lumbar laminectomy/ foraminotomy remains a procedure without established clinical efficacy.      

Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements (MILD procedure) (code 0275T) does not have final approval from the appropriate regulatory bodies for this diagnosis. 

Surgery is for only those who fail repeated nonoperative treatments. In most cases, surgical treatment of spinal stenosis is elective, aimed at improving symptoms and function rather than preventing neurologic complications, and merits consideration only after attempting nonsurgical modalities, or if a patient's symptoms result in disability. If a patient presents with rapidly progressive neurological deficits or if there is the presence of bladder dysfunction, urgent surgery is necessary. This situation may present in cases of cauda equina syndrome, conus medullaris syndrome, trauma, or an intraspinal canal tumor. The surgical approach is multilevel decompressive laminectomy with or without lumbar fusion. Lumbar fusion is generally reserved for patients with spondylolisthesis.

Another major issue in the minimally invasive spine (MIS) approaches shows in higher rates of reoperation for residual stenosis not adequately addressed in the initial operation. On the other hand, the Spinal Laminectomy versus Instrumented Pedicle Screw (SLIP) study provided level I evidence supporting decompression with fusion since one-third of patients undergoing standalone laminectomy developed instability within four years. The key issue is identifying those subsets of patients who are at risk of postoperative spinal instability in cases of grade I spondylolisthesis.

Lumbar fusion was associated with meaningful improvement in overall physical health-related quality of life than laminectomy alone. Paradoxically spinal fusion surgeries account for the highest aggregate hospital costs of any surgical procedure performed in U.S. (United States) hospitals. Advocating the same guidelines for patients in the middle and low-income nations is justifiable only if they provide durable clinical benefit. There have been few alternative solutions such as the use of interspinous distractors; however, though researchers observed fewer complications in these procedures, there were higher risks for redo surgery.

Recently, posterior fixation surgery with facet distraction, without decompression has shown to have good clinical outcomes among similar patients" (Munakomi, S., et al. 2022).                                                    

In summary, the denial of percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements (MILD procedure) (code 0275T) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.