Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain; leg pain.
Treatment: Spine Surgery (percutaneous laminotomy/laminectomy).
The insurer denied the Spine Surgery (percutaneous laminotomy/laminectomy).
The denial is upheld.

The patient is a male with low back and right leg pain. Records note a past evaluation by a Neurosurgeon, however, this report is not included in the provided clinical information. Patient has tried gabapentin without benefit and acupuncture with benefit.

The patient was prescribed meloxicam and encouraged to continue his home exercise program. Discussion indicates patient had recent vascular surgery for claudication, however, he continues to have lower extremity symptoms. Per note, the physician feels the pain is related to his back. At the next office visit, the provider indicates patient had a L4-5 (fourth lumbar spine vertebra-fifth lumbar
spine vertebra) ILESI (interlaminar epidural steroid injections) with improvement after 2 weeks. The recommendation was at this time for a right sided L4-5 (fourth lumbar spine vertebra-fifth lumbar
spine vertebra), L5-S1 (fifth lumbar spine vertebra-sacral base) TFESI (transforaminal lumbar epidural steroid injection). This was performed without benefit.

The recommendation was for a L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) ILESI (interlaminar epidural steroid injections) and MILD (minimally invasive lumbar decompression) procedure. MRI (magnetic resonance imaging) of the lumbar spine is significant for severe central spinal canal stenosis and impingement of the nerve roots of the cauda equina at L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) due to disc bulge and ligamentum flavum hypertrophy.

The request for MILD (minimally invasive lumbar decompression) was denied as not medically necessary.

No, the requested health service is not medically necessary.
There is not valid scientific evidence to show that the expected health benefits from the MILD (minimally invasive lumbar decompression) procedure are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments. The available evidence for MILD (minimally invasive lumbar decompression) has been continuously debated. Overall, it is considered that while the procedure is likely safe, there is only modest evidence for effectiveness.

The available studies are limited in patient size and/or duration. A publication of a prospective study does show efficacy and lack of adverse reactions at 6 months with 155 patients age 50-80. Based on a review of the available current scientific literature, the novel interventions for symptomatic lumbar spinal stenosis, such as the MILD (minimally invasive lumbar decompression) procedure and the Superion interspinous spacer, generally are evidenced to be safe and effective. There is a possibility in the future that these interventions could disrupt current treatment algorithms for lumbar spinal stenosis. However, more studies need to be done. As such at this time MILD (minimally invasive lumbar decompression) is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.