Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1:  The patient is a 26-year-old male with a history of low back pain and radicular symptoms to both legs, dating back to 2001. Conservative treatment had not been effective. MRI showed disc protrusions at L4-5 and L5-S1, but no frank nerve root compression and no clinical neurological deficits were described. Two-level endoscopic discectomy/thermal annuloplasty at L4-5 and L5-S1 was recommended by the patients provider and carried out In March 2006. The patient requested reimbursement from the Health Plan for the costs incurred. The Health Plan denied the patients request stating that percutaneous techniques for lumbar, thoracic or cervical discs, with or without endoscopic guidance, are considered investigational and were therefore not a covered benefit. Endoscopic, percutaneous decompression techniques are not widely used for spinal surgery and are not generally accepted as proven and effective treatment options. Despite the experience level of the patients provider, endoscopic discectomy and thermal annuloplasty have not been shown to provide greater relief than standard treatment modalities. As such, I have determined that the procedures at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2:  The patient is a 26-year-old male with a five-year history of low back pain and radiculopathy. His neurosurgeon indicated that conservative therapy had not been effective for treatment of the patients symptoms. The provider recommended endoscopic discectomy with thermal annuloplasty at L4-5 and L5-S1. The patient went ahead with the procedures and subsequently requested reimbursement. The Health Plan considered these procedures experimental and denied the patients request.Endoscopic discectomy is an experimental procedure without established safety and efficacy. There is no Class I long-term data demonstrating an advantage to this procedure over open laminectomy decompression. The literature does not support endoscopic discectomy as the standard of care for disc herniation in the lumbar spine and traditional laminectomy is still the gold standard for patients such as this one. Therefore, I have determined the procedures at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3:  The patient is a 26-year-old male who had chronic low back pain. MRI (January 2006) showed disc protrusion at L4-5 and L5-S1 and mild foraminal stenosis at L4-5. His provider recommended the patient undergo endoscopic discectomy and thermal annuloplasty at L4-5 and L5-S1; the surgery was accomplished in March 2006. The Health Plan considered endoscopic discectomy and thermal annuloplasty experimental procedures and denied the patients request for reimbursement.Among the emerging therapeutic options for the treatment of back pain and radiculopathy are a plethora of minimally invasive treatments which involve the removal of nuclear material to lower intradiscal pressure through percutaneous insertion of a device into an intervetebral disc. There is as yet a compelling lack of clinical evidence to support the use of these procedures. Freeman, et al, showed there was no significant benefit with intradiscal electrothermal therapy (IDET) over placebo and the Cohen study demonstrated that nucleoplasty is not an effective long-term treatment for lumbar radiculopathy, either alone or with IDET. Endoscopic discectomy and thermal annuloplasty are experimental/investigational procedure without established clinical efficacy. Based on the information set forth above, I have determined that the procedures at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.