Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lumbar Region Radiculopathy.
Treatment: Low Back Surgery (Lumbar Laminotomy/Microdiscectomy).
The health plan denied the requested surgical procedure. 
The health plan's determination is upheld.

The patient is a male. He was seen in orthopedic clinic for right posterior thigh pain. He developed left posterior leg pain skiing . He had worsening dull aching pain which caused him to stop skiing for the day. He went to bed and woke up the next morning with the inability to weight-bear through the right leg due to pain in the leg. The pain is worsened with sitting, prolonged standing, and is relieved by lying down. It radiates from the gluteal region down the posterior thigh and is associated with numbness and tingling in the right foot. He was given a Medrol Dosepak 1 week previously and noted no improvement. He continues to be unable to bear weight or stand on the right leg and is using crutches for ambulation. An MRI showed moderate right paracentral disc extrusion/herniation with inferior migration flattening the traversing right S1 (sacral) nerve root, displacing the traversing left S1 nerve root and causing moderate to severe spinal canal stenosis. The patient underwent a right L5-S1 laminotomy with microdiscectomy and exploration of the right S1 nerve root and right L5-S1 epidural Dexamethasone injection. The procedure was tolerated well with no intraoperative complications noted. The patient subsequently had an uneventful postoperative course with resolved symptoms and return to normal activity.

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

No, the requested lumbar microdiscectomy is not medically necessary for this patient.
As per the physical exam findings, there were no bowel or bladder issues, no saddle anesthesia, no cauda equina signs or symptoms, and there were not significant and progressive neurological deficits documented. Without these findings, there is no evidence that would preclude a treatment period of 6 to 8 weeks of conservative therapies which is the current standard of care prior to proceeding with surgical intervention.
Current peer-reviewed literature demonstrates conservative treatment for lumbar disc herniation will result in significant improvement in symptoms if applied over 6 to 8 weeks' timeframe. If unsuccessful over that timeframe and there has not been progressive neurological loss, surgical intervention can be considered at that time. The most widely accepted indications per current literature for discectomy in the absence of progressive neurological deficit or cauda equina syndrome, is the failure of conservative treatment and failure of epidural steroid injections to relieve symptomatology.
The patient did not have symptoms of cauda equina or an urgent surgical necessity. The current standard of care and peer-reviewed literature strongly supports 6 to 8 weeks of conservative therapies prior to proceeding with lumbar microdiscectomy. There was an absence of significant neurological deficits and findings and no significant documented progression of neurological issues. Therefore, conservative treatment could have been attempted as per the standard of care for the treatment of lumbar disc herniation.