Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Spinal Stenosis
Treatment: Minimal invasive lumbar decompression (MILD) 
The insurer denied the minimal invasive lumbar decompression (MILD).
The health plan's determination is upheld.

The patient is a female who is diagnosed with lumbar spinal stenosis and degenerative disc disease. Records show the patient was recommended to undergo a minimally invasive lumbar decompression (MILD) procedure, which was denied by the insurance carrier as experimental and investigational.
The letter of appeal from the provider states that the patient has intermittent neurogenic claudication due to central lumbar spinal stenosis and has thus far failed conservative measures including physical therapy, nonsteroidal anti-inflammatory medications and epidural steroid injections. The patient is now recommended for minimally invasive lumbar decompression to remove thickened ligaments that contribute to central canal stenosis from the posterior aspect of the vertebral column and states that this procedure has been shown to be superior to epidural injections with respect to functional improvement in pain relief. It was felt that the procedure poses far less risk than open surgical decompression and the patient may not be a good candidate for that given their age and underlying medical comorbidities.
The magnetic resonance imaging (MRI) of the lumbar spine revealed progressive degenerative disc disease, degenerative lumbar vertebrae (L)4 - L5 spondylolisthesis with increased now moderate central canal stenosis and bilateral neural foraminal narrowing and new small left disc protrusion at L1 - L2.
The progress note notes the patient was seen with complaints of low back pain traveling to both hips rated at 6 out of 10 currently in ranges from 6 to 8 out of 10. She reports Motrin and Tylenol help somewhat. Nerve blocks have been short-lived but helpful. She does a home exercise program with stretching and walking on a daily basis and did physical therapy years ago but did not find it significantly helpful at that time. She had a lumbar epidural injection. Current medications include Amlodipine, Citalopram, Dilantin, Estradiol, Hydralazine, and Hydrochlorothiazide. The physical examination revealed mild tenderness to palpation at the lumbar spine, bilateral paraspinous region, negative facet challenge bilaterally, moderate left sciatic notch tenderness, minimal right sciatic notch tenderness. There was positive straight leg raise on the left, negative on the right. Strength was 5 out of 5 in the lower extremities and sensation was normal. The plan was to pursue the MILD procedure.

Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended. Mild (minimally invasive lumbar decompression), from Vertos Medical, Inc., describes a percutaneous procedure for decompression of the central spinal canal in patients with lumbar spinal stenosis. In contrast to surgical decompression, the mild procedure is a percutaneous decompressive procedure performed solely under fluoroscopic guidance (e.g., without endoscopic or microscopic visualization of the work area). This procedure is indicated for central stenosis only, without the capability of addressing nerve root compression or disc herniation, should it be required.
Due to the unknown impact of these limitations on health outcomes, randomized controlled trials in appropriate patients are needed to compare this new procedure with established alternatives." The patient is noted to have a history of chronic back pain. It appears the only medications being used for pain include over-the-counter Motrin and Tylenol. The patient had epidural injections that were helpful but short term. It was noted she does a home exercise program but has not had physical therapy for years. This procedure is considered experimental and investigational due to insufficient evidence that this treatment improves overall net health outcome as compared to traditional means of treatment for this condition.

The health plan's determination regarding the proposed health service or treatment is upheld in whole.