Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low Back Pain.

Treatment minimally invasive left lumbar (L) 3 hemilaminectomy, medial facetectomy, left L3-4 microdiscectomy and left L4 hemilaminotomy, medial facetectomy, and left L4-5 microdiscectomy (codes 63030, 63035 and 69990).

The insurer denied coverage for minimally invasive left lumbar (L) 3 hemilaminectomy, medial facetectomy, left L3-4 microdiscectomy and left L4 hemilaminotomy, medial facetectomy, and left L4-5 microdiscectomy (codes 63030, 63035 and 69990).

The denial is overturned.

This case involves a patient with a diagnosed of low back pain, other intervertebral disc displacement of the lumbar region, and radiculopathy of lumbar region.  

Magnetic resonance imaging (MRI) of the patient's lumbar spine was obtained secondary to a five-year history of low back pain without known history of accident or trauma.  The findings noted a combination of disc bulging and mild to moderate facet joint hypertrophic bony overgrowth that resulted in moderate right-sided lateral recess encroachment at the lumbar (L) 2-3 and L4-5-disc levels and moderate left-sided lateral recess encroachment at the L3-4-disc level.  There was mild left-sided foraminal encroachment at the L3-4-disc level.  There were prominent endplate degenerative changes of the posterior aspect of the L3-4-disc level with a prominent Modic type I changes.  There was a Schmorl's node and endplate marrow edema along the superior endplate of L5.  There was moderate anterior spurring disc bulging and bridging osteophyte formation at the L1-2, L2-3, L3-4, and L4-5-disc levels compatible with degenerative disc disease.  

The patient reported a six-month history of low back pain.  The pain was gradual in onset.  He rated his pain five out of ten.  His pain was aggravated with sitting and lifting.  The pain radiated to the left hip and left lower extremity.  He endorsed numbness in the left lower extremity.  He denied any weakness.  It was stated that the patient had recent lumbar physical therapy, three lumbar epidural steroid injections, chiropractic treatments, and acupuncture with no long-lasting pain relief.  The physical exam findings of the patient noted normal muscle bulk and tone in all four extremities.  The patient had good strength in all muscle groups.  Light touch, pinprick, and proprioceptive sensation were all grossly normal in all four extremities.  There was mild tenderness to palpation in the mid to lower posterior lumbar region.  There was decreased lumbar range of motion in all planes.  The patient's gait was normal.  The Romberg testing was negative.  The straight leg raise test was negative bilaterally.  The patient had L3-4 posterolateral lumbar disc herniation and severe left L3-4 lumbar lateral recess stenosis.  There was also moderate left L4-5 lumbar lateral recess stenosis and left L4-5 paracentral lumbar disc protrusion.  There was strong concordance between the patient's clinical findings and radiological picture.  The provider stated that the patient had exhausted all conservative treatment options including physical therapy and an epidural steroid injection.  The provider recommended that the patient undergo minimally invasive left L3 hemilaminectomy, medial facetectomy, left L3-4 microdiscectomy, and left L4 hemilaminotomy, medial facetectomy, and left L4-5 microdiscectomy.

According to the cited references, surgery is indicated for patients who have objective and subjective clinical findings of spinal stenosis, confirmed on imaging, who have failed nonoperative treatment.  The previous request for surgical intervention was denied as there was a lack of at least moderate central/moderate left foraminal and/or moderate left lateral recess stenosis at the planned surgical levels on imaging and a lack of physical therapy notes documenting six weeks of formal physical therapy or therapist note stating why physical therapy was contraindicated that was dated within the past year.  The patient continued to endorse low back pain and left-sided lower extremity symptoms.  The patient had not responded to at least six months of conservative management including physical therapy.  Proceeding with the requested surgical procedure is appropriate based on the clinical findings and cited references.  An addended reading of the patient's lumbar magnetic resonance imaging noted broad-based disc bulging at L3-4-disc level represented a broad-based contained herniation that contributed to moderate left-sided lateral recess encroachment at the L3-4 level disc level, representing a possible source of left L4 radiculopathy 

Thus, proceeding with the requested surgery is medically necessary.  As such, the health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the minimally invasive left lumbar (L) 3 hemilaminectomy, medial facetectomy, left L3-4 microdiscectomy and left L4 hemilaminotomy, medial facetectomy, and left L4-5 microdiscectomy (codes 63030, 63035 and 69990) is overturned. Medical Necessity is substantiated.