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 the diagnosis of low back pain. The patient's doctor performed nucleogram and diskectomy at lumbar (L)2-3 and L4-5.  It was noted that the magnetic resonance imaging (MRI) showed retrolisthesis at L1-2 and L2-3 and a synovial cyst on the right at L5-Sacral (S)1. The procedure notes states, positive straight leg raise (SLR) on the right. MRI L-spine stand-up shows: Convex right curvature with straightening of lordosis; diffuse loss of disk signal with additional loss of disk height at L-2, L-3, and L3-4; Modic endplate degeneration is noted at L2-3 and L3-4 and a disk bulge asymmetric to the right as noted at thoracic (T)12-L1, L5-S1 facet arthrosis was noted with three millimeter (mm) synovial cyst in the right facet joint. The treating provider has recommended endoscopic decompression and electrothermal annuloplasty, which is under medical review.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

Risks of endoscopic and electrothermic treatment include persistent pain and progressive spinal degeneration.

Given that the treatment administered was not well designed to resolve the diffuse degenerative findings noted on MRI, the risks of the treatment administered are increased over further nonsurgical care or standard surgical decompression and/or fusion.

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.