Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain

Treatment: Outpatient percutaneous image-guided lumbar decompression procedure

The insurer denied coverage for outpatient percutaneous image-guided lumbar decompression procedure

The denial is upheld

Reviewer Number (#) 3:

The patient is an adult female with a history of lumbar spine pain. The physical exam shows pain and limited range of motion. There was positive facet loading. The request is for outpatient percutaneous lumbar decompressive procedure, which is under medical review.

The peer-reviewed literature does not support a result of improvement in health outcomes.

The outpatient percutaneous image-guided lumbar decompression procedure needs final approval from the appropriate regulatory bodies for this diagnosis. The procedure does not have final review from the appropriate regulatory bodies.     

An outpatient percutaneous image-guided lumbar decompression procedure is not the best available treatment for this patient at this time. 

The adverse risks are increased over standard treatment/services. 

"Lumbar spinal stenosis is a common source of leg and back pain. It refers to a narrowing in the vertebra, in the areas of the central canal, lateral recess or the neural foramen. When Lateral recess and neural foramen are stenosed, symptoms of lumbar radiculopathy may also be demonstrated. Despite its prevalence, currently, there is no universally accepted definition of lumbar spinal stenosis, and there is also a lack of generally accepted radiologic diagnostic criteria. Lumbar spinal stenosis is a significant cause of disability in the elderly, and it is the most significant cause of spinal surgery in patients over 65 years of age" (Wu, L., Cruz, R. 2022).

"This study provides evidence that the use of minimally invasive surgical techniques (MIS) to treat multilevel lumbar stenosis is clinically effective and durable up to 2 years postoperatively with low rates of complications and reoperations. These data may support the creation of a randomized prospective trial to provide a more robust evidence base comparing MIS with open techniques in multilevel decompressive procedures in the lumbar spine. MIS is quickly progressing to becoming not simply an established surgical method for lumbar stenosis but perhaps the preferred surgical technique pending additional investigation" (Khanna, R., and others (et al.) 2021).

"Lumbar spinal stenosis is a common degenerative spine condition. In properly selected patients, minimally invasive lumbar decompression (MILD) may be an option to improve outcomes. This review provides an in-depth description of the MILD procedure and a comprehensive examination of safety and efficacy. Two randomized controlled trials, together with 11 other controlled clinical studies, have established the efficacy of MILD, which is a minimally invasive procedure that does not involve implants and has demonstrated excellent efficacy and safety. With an established safety profile equivalent to epidural steroid injections, and efficacy that has been shown to be superior to such injections, MILD can reasonably be positioned early in the treatment algorithm for these patients. Based on extensive review of the literature, robust safety and efficacy through 2 years, and in accordance with minimally invasive spine treatment guidelines, MILD is recommended as the first intervention after failure of conservative measures for lumbar spinal stenosis patients with neurogenic claudication and ligamentum flavum hypertrophy" (Jain, S., et al. 2020).                                                    

In summary, the denial of an outpatient percutaneous image-guided lumbar decompression procedure (MILD) 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.