Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Lumbar decompression
The insurer denied coverage for lumbar decompression.
The denial is upheld.

This is an adult patient with chronic back pain with magnetic resonance imaging (MRI) findings of multilevel neural foraminal stenosis and multilevel degenerative disc and joint changes. Her pain radiates into the right groin, thigh, and lower extremities. The patient has taken anticonvulsants, Lyrica, and oxycodone, which have been effective. There is no documentation of failed conservative measures such as physical therapy (PT) other than postoperative PT after total hip replacement. It is documented that the patient had only 2 weeks of pain relief after lumbar transforaminal injections at lumbar (L) 3-L4 and L4-L5. The provider is requesting approval for 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 (e.g. ["for example"], 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 or disc herniation, 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 had 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, so 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 of these newer procedures offer benefit 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. Centers for Medicare & Medicaid Services (CMS) 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 (CED).

The patient has chronic back pain and severe spinal stenosis and has failed conservative treatment including medication and transforaminal injections. The procedure does not have approval from regulatory bodies for routine use. 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.

This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are substantially increased over standard treatments.

The carrier's denial of coverage for lumbar decompression should be upheld.