Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lumbar spinal stenosis and neurogenic claudication.

Treatment: Percutaneous laminectomy (0275T).

The insurer denied coverage for percutaneous laminectomy (0275T).

The denial is overturned.

This is a male with a history of neurogenic claudication due to severe lumbar spinal stenosis (LSS) at Lumbar (L) 4-5. He has pain in the bilateral legs only when standing and walking and relieved with sitting. He has failed physical therapy, medications and intralaminar epidural steroid injections. He is restricted in his activities of daily living and his pain ranges from 6-9/10. His lumbar magnetic resonance imaging (MRI) report notes moderate to severe central canal stenosis due to ligamentum hypertrophy, moderate left and severe right foraminal stenosis.

There is sufficient evidence in peer-reviewed literature to support improvement in health outcome.

One-year results of this randomized controlled clinical trial demonstrate that minimally invasive lumbar decompression (MILD) is statistically superior to epidural steroid injection (ESIs) in the treatment of LSS patients with neurogenic claudication and verified central stenosis due to ligamentum flavum hypertrophy. (1)

Lumbar spinal stenosis is a degenerative condition that affects millions of people that present with radicular buttock and leg pain and neurogenic claudication. In those moderate to severe cases when conservative treatment (physical therapy, analgesics) and epidural steroid injections have failed, many patients have to rely on invasive surgical procedures which involve general anesthesia, hospital admission, surgical revisions, as well as morbidities and mortalities. Thus, the development of minimally invasive procedures that reduce the risks associated with surgical interventions is welcomed. Percutaneous image-based lumbar decompression (PILD) is a term that covers ultra-minimally invasive procedures that involve minimal manipulation of lumbar spinal structures without device implantation. Studies have demonstrated PILD to be effective for patients with lumbar spinal canal stenosis with neurogenic claudication due to hypertrophic ligamentum flavum who have failed conservative treatment. Besides, it is a procedure that requires local anesthesia, can be performed in outpatient setting, and no significant adverse events have been reported. (2)

MILD has been shown to be safe and effective for the treatment of lumbar spinal stenosis patients with hypertrophic ligamentum flavum as a contributing factor. This study examines the long-term durability of the mild procedure through 5-year follow-up. Pain relief and opioid medications utilization during 12-month follow-up were also assessed. (3)

The procedure is Food and Drug Administration (FDA) approved and is medically necessary per Centers for Medicare & Medicaid Services (CMS) for this diagnosis of spinal stenosis with neurogenic claudication.

The patient is a good candidate for this procedure. The patient has neurogenic claudication due to moderate/severe central stenosis caused by ligamentum hypertrophy and has failed conservative treatment. He has significant pain and loss of function. 

He has failed all conservative treatments and has significant pain and functional decline.

Other treatments for his condition would include a lumbar fusion which carries increased adverse risk versus the requested procedure. The PILD procedure is more likely to be beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of percutaneous laminectomy (0275T) should be overturned.