Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: Current procedural terminology (CPT) code 62380 [endoscopic decompression of spinal cord, nerve root, including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar], CPT code 22526 [percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level], CPT code 22527 [percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral, including fluoroscopic guidance; 1 or more additional levels], and CPT code 76000 [fluoroscopy (separate procedure), up to 1 hour physician or other qualified healthcare professional time]. 
The insurer denied coverage for current procedural terminology (CPT) code 62380 [endoscopic decompression of spinal cord, nerve root, including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar], CPT code 22526 [percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level], CPT code 22527 [percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral, including fluoroscopic guidance; 1 or more additional levels], and CPT code 76000 [fluoroscopy (separate procedure), up to 1 hour physician or other qualified healthcare professional time]. 
The denial is upheld. 

The patient has a history of back pain. The patient's treating provider has requested authorization for lumbar endoscopic laminotomy and two level intradiscal electrothermal annuloplasty, which is under review. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. Neither of the requested procedures have been shown to have clinical efficacy. There is no peer-reviewed literature that supports improvement in health outcome. 

The adverse risks are markedly increased over standard treatment/services. 

The patient has a history of back pain with lumbar endoscopic laminotomy and two level intradiscal electrothermal annuloplasty being requested. However, these services are no more likely to be more beneficial than any of the standard treatments/procedures for this patient. 

As such, the request is denied. 

In summary, the denial of current procedural terminology (CPT) code 62380 [endoscopic decompression of spinal cord, nerve root, including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar], CPT code 22526 [percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level], CPT code 22527 [percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral, including fluoroscopic guidance; 1 or more additional levels], and CPT code 76000 [fluoroscopy (separate procedure), up to 1 hour physician or other qualified healthcare professional time], 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 risk are substantially increased over standard treatments.