Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain

Treatment: outpatient minimally invasive lumbar decompression (MILD) procedure (back surgery) (code 0275T)

The insurer denied coverage for outpatient minimally invasive lumbar decompression (MILD) procedure (back surgery) (code 0275T)

The denial is upheld

This is an adult patient with intermittent neurogenic claudication due to lumbar spinal stenosis. The patient has low back pain rated at 5/10, with occasional pain down the left leg, worse with prolonged walking and bending. The patient has been treated in the past with an interlaminar epidural steroid injection (ESI). The patient takes Lyrica and Celebrex. The symptoms have lasted about one year. The patient has tried home exercises, and activity modification. Magnetic Resonance Imaging (MRI) shows multilevel degenerative disc disease, with Lumbar (L)4-L5 moderate to severe central canal stenosis and L4-5, L5-Sacral (S)1 posterior disc bulge. The MRI also shows evidence of multilevel facet joint hypertrophy, with severe bilateral facet joint hypertrophy at L4-5. The treating physician recommended the minimally invasive lumbar decompression (MILD) procedure.

The MILD procedure is generally described as a noninvasive procedure using specially designed instruments to percutaneously remove a portion of the lamina and debulk the ligamentum flavum. The procedure is performed under x-ray guidance (such as fluoroscopic, computed tomography) with contrast media to identify and monitor the compressed area via epidurogram. This procedure is indicated for central stenosis only, without the capability of addressing nerve root compression, disc herniation, or facet joint hypertrophy should it be required. Systematic review found that current evidence does not support the routine use of minimally invasive surgery for cervical or lumbar discectomy and the benefits to long-term health outcomes are unknown. Minimally invasive surgery has no clinically significant advantage in terms of short or long-term measures of pain or function. Open discectomies are already performed through relatively small incisions, it is not surprising to find that outcomes are no better with minimally invasive discectomies. UpToDate notes that less invasive decompression procedures, such as the MILD procedure, appear in observational studies to have lower complication rates than traditional surgical techniques. However, it is unclear if these newer procedures offer benefits in terms of improved symptoms and function or fewer complications in routine practice compared with standard decompression with laminectomy. The North American Spine Society makes no specific recommendations on percutaneous image-guided lumbar decompression. The Centers for Medicare and Medicaid Services has determined that percutaneous image-guided lumbar decompression is not reasonable and necessary and is covered only when provided in an approved clinical study, through coverage with evidence development.

The patient has chronic back and leg pain with spinal stenosis and severe bilateral facet joint hypertrophy, who has failed conservative treatment including medication, physical therapy, and epidural steroid injections. The treating physician is recommending the MILD procedure. The procedure does not have approval from regulatory bodies for routine use. This patient has severe bilateral facet joint hypertrophy that would not be addressed by this procedure. The requested procedure is not considered standard of care in the general medical community, as there are significant risks and limitations with this procedure, and it is not found to be more effective than that of a traditional open discectomy.

In summary, the denial of outpatient MILD procedure (back surgery) (code 0275T) 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.